Provider Demographics
NPI:1659835882
Name:LANDRY, LANE THOMAS
Entity Type:Individual
Prefix:
First Name:LANE
Middle Name:THOMAS
Last Name:LANDRY
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 1:1061 OSCAR GUIDRY RD
Mailing Address - Street 2:
Mailing Address - City:SAINT MARTINVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70582-6213
Mailing Address - Country:US
Mailing Address - Phone:337-680-1002
Mailing Address - Fax:
Practice Address - Street 1:1061 OSCAR GUIDRY RD
Practice Address - Street 2:
Practice Address - City:SAINT MARTINVILLE
Practice Address - State:LA
Practice Address - Zip Code:70582-6213
Practice Address - Country:US
Practice Address - Phone:337-680-1002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-22
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
20000352792255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer