=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477940674
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR. MARC LANDES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/25/2015
-----------------------------------------------------
Last Update Date | 01/27/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 905 SINGLETARY DR
-----------------------------------------------------
City | STREETSBORO
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44241-3975
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-422-2168
-----------------------------------------------------
Fax | 330-422-2170
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2234 CROSS CREEK TRL
-----------------------------------------------------
City | CUYAHOGA FALLS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44223-1273
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-606-2880
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MARC TODD LANDES
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 330-606-2880
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 6212
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------