Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251X0800X | Physical Therapist - Orthopedic | LPT31413 | AZ |
NPI | 1003427444 |
---|---|
Provider Name | Mr. Landis Randall Mains |
First Address | Phoenix, AZ 85027-1075 |
Second Address | Glendale, AZ 85307-3005 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/08/2020 |
Last Update Date | 10/08/2020 |