=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568559714
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAND MEDICAL, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/09/2006
-----------------------------------------------------
Last Update Date | 07/09/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4 NESHAMINY INTERPLEX DR STE 101
-----------------------------------------------------
City | FEASTERVILLE TREVOSE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19053-6940
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-294-6790
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4 NESHAMINY INTERPLEX DR STE 101
-----------------------------------------------------
City | FEASTERVILLE TREVOSE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19053-6940
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-294-6790
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHAIRMAN/CEO
-----------------------------------------------------
Name | DR. HENRY I BALOGUN
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 267-993-0256
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | 101200
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2084P0804X
-----------------------------------------------------
Taxonomy Name | Child & Adolescent Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------