Healthcare Provider Details

I. General information

NPI: 1598750176
Provider Name (Legal Business Name): RICHARD CHARLES LANDON MSPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2005
Last Update Date: 11/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1812 MARSH RD STORE 505
WILMINGTON DE
19810-4581
US

IV. Provider business mailing address

790 REMINGTON BLVD
BOLINGBROOK IL
60440-4909
US

V. Phone/Fax

Practice location:
  • Phone: 302-475-7500
  • Fax: 302-475-5787
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT015816
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberJ1-0002838
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: