MEDICARE: MR. KEITH SCOTT LANDHERR OTR/L

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	172V00000X	Community Health Worker	05789	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	05789	OTHER	NY	NYS LICENSE# 5789

General Provider Information

NPI Number	:	1689828139
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. KEITH SCOTT LANDHERR OTR/L

Provider Business Mailing Address
First Line	:	2400 JOHNSON AVE
Second Line	:	#1-C
City	:	BRONX
State	:	NY
Zip	:	10463-6464
Country	:	US
Telephone Number	:	718-601-3629
Fax Number	:	718-601-3629

Provider Business Practice Location Address
First Line	:	2400 JOHNSON AVE
Second Line	:	#1-C
City	:	BRONX
State	:	NY
Zip	:	10463-6464
Country	:	US
Telephone Number	:	718-601-3629
Fax Number	:	718-601-3629

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/11/2008
Last Update Date	:	11/11/2008

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