Provider Demographics
NPI:1407337181
Name:LAND, BRIAN MICHAEL (MPT)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:MICHAEL
Last Name:LAND
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:931 LAKE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MO
Mailing Address - Zip Code:63755-2629
Mailing Address - Country:US
Mailing Address - Phone:573-270-7985
Mailing Address - Fax:
Practice Address - Street 1:1020 S PARKWAY ST
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-7704
Practice Address - Country:US
Practice Address - Phone:573-270-7985
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-22
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005006165225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty