Healthcare Provider Details

I. General information

NPI: 1780579326
Provider Name (Legal Business Name): JUSTIN RICHARD LANDA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2025
Last Update Date: 06/12/2025
Certification Date: 06/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

931 10TH ST STE 776
MODESTO CA
95354-2305
US

IV. Provider business mailing address

723 TANNER CT
MERCED CA
95341-8905
US

V. Phone/Fax

Practice location:
  • Phone: 832-489-3172
  • Fax:
Mailing address:
  • Phone: 714-722-3015
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License NumberRBT-24-373536
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: