1558403915 NPI number — LANDRUM, INC.

Table of content: (NPI 1558403915)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558403915 NPI number — LANDRUM, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LANDRUM, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1558403915
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
542 WILLIAMSON RD
Provider Second Line Business Mailing Address:
SUITE 5
Provider Business Mailing Address City Name:
MOORESVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28117-8193
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-663-1065
Provider Business Mailing Address Fax Number:
704-660-1851

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
542 WILLIAMSON RD
Provider Second Line Business Practice Location Address:
SUITE 5
Provider Business Practice Location Address City Name:
MOORESVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28117-8193
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-663-1065
Provider Business Practice Location Address Fax Number:
704-660-1851
Provider Enumeration Date:
02/13/2007

Additional Information

Authorized Official

Authorized Official Last Name:
LANDRUM
Authorized Official First Name:
TRACY
Authorized Official Middle Name:
RAY
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
704-663-1065

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  HC3210 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3418114 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6601413 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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