Healthcare Provider Details

I. General information

NPI: 1679304513
Provider Name (Legal Business Name): LANDON BERTRAM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2024
Last Update Date: 08/12/2024
Certification Date: 08/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3392 MOTOR AVE
LOS ANGELES CA
90034-3712
US

IV. Provider business mailing address

1360 S FIGUEROA ST APT 417
LOS ANGELES CA
90015-2884
US

V. Phone/Fax

Practice location:
  • Phone: 310-742-2230
  • Fax:
Mailing address:
  • Phone: 313-919-0298
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number52838
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: