Provider Demographics
NPI:1295471787
Name:WATERS, LANDON MILES
Entity Type:Individual
Prefix:
First Name:LANDON
Middle Name:MILES
Last Name:WATERS
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 1:727 E WYANDOTTE AVE
Mailing Address - Street 2:
Mailing Address - City:MCALESTER
Mailing Address - State:OK
Mailing Address - Zip Code:74501-5427
Mailing Address - Country:US
Mailing Address - Phone:918-420-5343
Mailing Address - Fax:918-420-5904
Practice Address - Street 1:727 E WYANDOTTE AVE
Practice Address - Street 2:
Practice Address - City:MCALESTER
Practice Address - State:OK
Practice Address - Zip Code:74501-5427
Practice Address - Country:US
Practice Address - Phone:918-420-5343
Practice Address - Fax:918-420-5904
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-09
Last Update Date:2022-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator