Healthcare Provider Details

I. General information

NPI: 1144283524
Provider Name (Legal Business Name): CLINT VANLANDINGHAM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2006
Last Update Date: 05/15/2020
Certification Date: 05/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 KANELL BLVD
POPLAR BLUFF MO
63901-3001
US

IV. Provider business mailing address

2600 KANELL BLVD
POPLAR BLUFF MO
63901-3001
US

V. Phone/Fax

Practice location:
  • Phone: 573-785-4546
  • Fax:
Mailing address:
  • Phone: 573-785-4546
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number2004001321
License Number StateMO

VIII. Authorized Official

Name: MR. CLINT VANLANDINGHAM
Title or Position: OWNER
Credential: DPM
Phone: 573-785-4546