Healthcare Provider Details

I. General information

NPI: 1649874959
Provider Name (Legal Business Name): ERIC LANDIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/27/2020
Last Update Date: 11/27/2020
Certification Date: 11/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10103 BAKER RD
SAINT LOUISVILLE OH
43071-9786
US

IV. Provider business mailing address

10103 BAKER RD
SAINT LOUISVILLE OH
43071-9786
US

V. Phone/Fax

Practice location:
  • Phone: 740-404-0663
  • Fax:
Mailing address:
  • Phone: 740-404-0663
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171WH0202X
TaxonomyHome Modifications Contractor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: