Healthcare Provider Details

I. General information

NPI: 1144738469
Provider Name (Legal Business Name): LANDMARK MEDICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2018
Last Update Date: 10/08/2020
Certification Date: 10/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3624 W ANTHEM WAY STE 108
ANTHEM AZ
85086-0440
US

IV. Provider business mailing address

2340 W PARKSIDE LN STE H107
PHOENIX AZ
85027-1274
US

V. Phone/Fax

Practice location:
  • Phone: 435-760-5896
  • Fax:
Mailing address:
  • Phone: 602-354-5310
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5090
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP5002
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number8503
License Number StateAZ
# 5
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number46628
License Number StateAZ
# 6
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number12547
License Number StateAZ

VIII. Authorized Official

Name: DR. JUSTIN D THOMPSON
Title or Position: MANAGER
Credential:
Phone: 435-760-5896