Provider Demographics
NPI:1336229954
Name:LANDIS, CARL D (ATC)
Entity Type:Individual
Prefix:MR
First Name:CARL
Middle Name:D
Last Name:LANDIS
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:953 HANDLEBAR RD
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46544-6647
Mailing Address - Country:US
Mailing Address - Phone:574-258-9091
Mailing Address - Fax:
Practice Address - Street 1:953 HANDLEBAR RD
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46544-6647
Practice Address - Country:US
Practice Address - Phone:574-258-9091
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36000124A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer