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General NPI Number Information
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NPI Number | 1184799520
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Entity Type | Organization
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Legal Business Name | KENNETH LANDIS M D A MEDICAL CORPORATION
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Dates
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Enumeration Date | 11/21/2006
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Last Update Date | 04/20/2017
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Provider Practice Location Address
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Address Line | 4644 LINCOLN BLVD SUITE 500
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City | MARINA DEL REY
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State | CA
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Zip | 90292-6313
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Country | US
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Telephone | 310-822-2255
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Fax | 310-822-0044
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Provider Business Mailing Address
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Address Line | 4644 LINCOLN BLVD SUITE 500
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City | MARINA DEL REY
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State | CA
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Zip | 90292-6313
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Country | US
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Telephone | 310-822-2255
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Fax | 310-822-0044
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. KENNETH WAYNE LANDIS
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Credential | M.D.
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Telephone | 310-822-2255
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RC0200X
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Taxonomy Name | Critical Care Medicine (Internal Medicine) Physician
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License Number | G29787
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 207RP1001X
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Taxonomy Name | Pulmonary Disease Physician
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License Number | G29787
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License Number State | CA
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Taxonomy #3
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | G29787
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License Number State | CA
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