Healthcare Provider Details

I. General information

NPI: 1932299690
Provider Name (Legal Business Name): LANDER MEDICAL CLINIC, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 04/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

745 BUENA VISTA
LANDER WY
82520-3431
US

IV. Provider business mailing address

PO BOX 9432
BELFAST ME
04915-9432
US

V. Phone/Fax

Practice location:
  • Phone: 307-332-2941
  • Fax: 307-332-1920
Mailing address:
  • Phone: 307-332-2941
  • Fax: 307-332-1920

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateWY
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number0823410001
License Number StateWY
# 3
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: RYAN L HEDGES
Title or Position: CEO
Credential:
Phone: 307-332-2941