Provider Demographics
NPI:1487892436
Name:LANDRA PROSTHETICS AND ORTHOTICS, INC
Entity type:Organization
Organization Name:LANDRA PROSTHETICS AND ORTHOTICS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:LANDRA
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:734-242-4050
Mailing Address - Street 1:PO BOX 34
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48183-0034
Mailing Address - Country:US
Mailing Address - Phone:734-242-4050
Mailing Address - Fax:734-242-4090
Practice Address - Street 1:526 N TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48162-3337
Practice Address - Country:US
Practice Address - Phone:734-242-4050
Practice Address - Fax:734-242-4090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-29
Last Update Date:2010-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAME-0163611332B00000X, 335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5853380002Medicare NSC