Provider Demographics
NPI:1659458214
Name:LANDRA PROSTHETICS AND ORTHOTICS INC
Entity Type:Organization
Organization Name:LANDRA PROSTHETICS AND ORTHOTICS INC
Other - Org Name:LANDRA PROSTHETICS & ORTHOTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:LANDRA
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:734-281-8144
Mailing Address - Street 1:PO BOX 34
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48183-0034
Mailing Address - Country:US
Mailing Address - Phone:734-281-8144
Mailing Address - Fax:
Practice Address - Street 1:14725 NORTHLINE RD
Practice Address - Street 2:
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195-2407
Practice Address - Country:US
Practice Address - Phone:734-281-8144
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2009-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5853380001Medicare NSC