Provider Demographics
NPI:1770627440
Name:LAND, MICHAEL R (DPT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R
Last Name:LAND
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12831 6TH ST
Mailing Address - Street 2:SUITE C&D
Mailing Address - City:LILLIAN
Mailing Address - State:AL
Mailing Address - Zip Code:36549-4166
Mailing Address - Country:US
Mailing Address - Phone:251-962-2149
Mailing Address - Fax:251-961-3815
Practice Address - Street 1:12831 6TH ST
Practice Address - Street 2:SUITE C&D
Practice Address - City:LILLIAN
Practice Address - State:AL
Practice Address - Zip Code:36549-4166
Practice Address - Country:US
Practice Address - Phone:251-962-2149
Practice Address - Fax:251-961-3815
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTH3908225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51511982OtherBC BS AL
ALP44781Medicare UPIN