1689828139 NPI number — MR. KEITH SCOTT LANDHERR OTR/L

Table of content: MR. KEITH SCOTT LANDHERR OTR/L (NPI 1689828139)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689828139 NPI number — MR. KEITH SCOTT LANDHERR OTR/L

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LANDHERR
Provider First Name:
KEITH
Provider Middle Name:
SCOTT
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
OTR/L
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1689828139
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/11/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2400 JOHNSON AVE
Provider Second Line Business Mailing Address:
#1-C
Provider Business Mailing Address City Name:
BRONX
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10463-6464
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-601-3629
Provider Business Mailing Address Fax Number:
718-601-3629

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2400 JOHNSON AVE
Provider Second Line Business Practice Location Address:
#1-C
Provider Business Practice Location Address City Name:
BRONX
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10463-6464
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-601-3629
Provider Business Practice Location Address Fax Number:
718-601-3629
Provider Enumeration Date:
11/11/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 172V00000X , with the licence number:  05789 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 05789 . This is a "NYS LICENSE# 5789" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com