Healthcare Provider Details

I. General information

NPI: 1740520139
Provider Name (Legal Business Name): BRUCE LANDON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2013
Last Update Date: 03/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1813 WELLNESS LN
TRINITY FL
34655-5359
US

IV. Provider business mailing address

1813 WELLNESS LN
TRINITY FL
34655-5359
US

V. Phone/Fax

Practice location:
  • Phone: 727-376-3999
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. BRUCE N. LANDON
Title or Position: OWNER
Credential:
Phone: 727-376-3999