Provider Demographics
NPI:1003427444
Name:MAINS, LANDIS RANDALL (PT, DPT)
Entity Type:Individual
Prefix:MR
First Name:LANDIS
Middle Name:RANDALL
Last Name:MAINS
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3212 W WALTER WAY
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85027-1075
Mailing Address - Country:US
Mailing Address - Phone:520-861-4502
Mailing Address - Fax:
Practice Address - Street 1:9980 W GLENDALE AVE STE 110
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85307-3005
Practice Address - Country:US
Practice Address - Phone:623-242-6908
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-10
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPT314132251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic