Provider Demographics
NPI:1346511532
Name:DERU, LANDON (ATC-L)
Entity Type:Individual
Prefix:
First Name:LANDON
Middle Name:
Last Name:DERU
Suffix:
Gender:M
Credentials:ATC-L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3730 BRINKER AVE
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-2019
Mailing Address - Country:US
Mailing Address - Phone:801-928-3213
Mailing Address - Fax:
Practice Address - Street 1:3730 BRINKER AVE
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-2019
Practice Address - Country:US
Practice Address - Phone:801-928-3213
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-19
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program