Provider Demographics
NPI:1194069351
Name:VANLANDINGHAM, JUSTIN ALLEN
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:ALLEN
Last Name:VANLANDINGHAM
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 1:1515 N CENTER ST
Mailing Address - Street 2:SUITE 5
Mailing Address - City:LONOKE
Mailing Address - State:AR
Mailing Address - Zip Code:72086-2101
Mailing Address - Country:US
Mailing Address - Phone:501-676-5540
Mailing Address - Fax:501-676-6499
Practice Address - Street 1:1515 N CENTER ST
Practice Address - Street 2:SUITE 5
Practice Address - City:LONOKE
Practice Address - State:AR
Practice Address - Zip Code:72086-2101
Practice Address - Country:US
Practice Address - Phone:501-676-5540
Practice Address - Fax:501-676-6499
Is Sole Proprietor?:No
Enumeration Date:2012-11-12
Last Update Date:2012-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT3552225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5B641Medicare PIN