Provider Demographics
NPI:1437407764
Name:LANDON, EDWIN DALE JR (PTA)
Entity Type:Individual
Prefix:MR
First Name:EDWIN
Middle Name:DALE
Last Name:LANDON
Suffix:JR
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:428 BRIDGE ST NW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49504-5322
Mailing Address - Country:US
Mailing Address - Phone:616-451-4284
Mailing Address - Fax:616-451-4811
Practice Address - Street 1:428 BRIDGE ST NW
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49504-5322
Practice Address - Country:US
Practice Address - Phone:616-451-4284
Practice Address - Fax:616-451-4811
Is Sole Proprietor?:No
Enumeration Date:2012-08-16
Last Update Date:2012-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI55020002800225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant