Healthcare Provider Details

I. General information

NPI: 1689670788
Provider Name (Legal Business Name): P.J. LANDERS D.P.T., M.T.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2005
Last Update Date: 02/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 S POLK ST STE 2
COVINGTON LA
70433-2474
US

IV. Provider business mailing address

1010 S POLK ST STE 2
COVINGTON LA
70433-2474
US

V. Phone/Fax

Practice location:
  • Phone: 985-809-9088
  • Fax: 985-809-9270
Mailing address:
  • Phone: 985-809-9088
  • Fax: 985-809-9270

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberP.T.04633
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: