Healthcare Provider Details

I. General information

NPI: 1699238907
Provider Name (Legal Business Name): LANDRY OSTEOPATHIC HEALTHCARE PA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2019
Last Update Date: 06/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

871 COURT ST
AUBURN ME
04210-3903
US

IV. Provider business mailing address

871 COURT ST
AUBURN ME
04210-3903
US

V. Phone/Fax

Practice location:
  • Phone: 207-241-0401
  • Fax:
Mailing address:
  • Phone: 207-241-0401
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: CHARLES LANDRY
Title or Position: OWNER
Credential: DO
Phone: 207-241-0401