Healthcare Provider Details

I. General information

NPI: 1699176883
Provider Name (Legal Business Name): CALEB LANDRUM, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2014
Last Update Date: 09/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 HUNTER ST
ROCKMART GA
30153-1916
US

IV. Provider business mailing address

530 HUNTER ST
ROCKMART GA
30153-1916
US

V. Phone/Fax

Practice location:
  • Phone: 770-684-5650
  • Fax: 770-684-1539
Mailing address:
  • Phone: 770-684-5650
  • Fax: 770-684-1539

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: DR. JOHN CALEB LANDRUM
Title or Position: MANAGER
Credential: OD
Phone: 770-684-5650