Provider Demographics
NPI:1003466210
Name:LANDRUM, KIRK L
Entity Type:Individual
Prefix:
First Name:KIRK
Middle Name:L
Last Name:LANDRUM
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 1:43 LANDRUM RD
Mailing Address - Street 2:
Mailing Address - City:OVETT
Mailing Address - State:MS
Mailing Address - Zip Code:39464-3735
Mailing Address - Country:US
Mailing Address - Phone:601-319-5879
Mailing Address - Fax:
Practice Address - Street 1:23 MASON ST
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MS
Practice Address - Zip Code:39440-4437
Practice Address - Country:US
Practice Address - Phone:601-399-0547
Practice Address - Fax:601-425-7585
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-19
Last Update Date:2019-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSAT01772255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer