Provider Demographics
NPI:1124431424
Name:TATE, LANDON
Entity type:Individual
Prefix:
First Name:LANDON
Middle Name:
Last Name:TATE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2907 WILLIAMSON COUNTY PKWY
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-5256
Mailing Address - Country:US
Mailing Address - Phone:618-998-9894
Mailing Address - Fax:
Practice Address - Street 1:902 S MCLEANSBORO ST
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:IL
Practice Address - Zip Code:62812-3413
Practice Address - Country:US
Practice Address - Phone:618-439-4501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-04
Last Update Date:2014-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.006481225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant