Provider Demographics
NPI:1457098279
Name:LANDIS, BRAD ALLAN (AT, ATC)
Entity Type:Individual
Prefix:
First Name:BRAD
Middle Name:ALLAN
Last Name:LANDIS
Suffix:
Gender:M
Credentials:AT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3401 LUDINGTON ST
Mailing Address - Street 2:
Mailing Address - City:ESCANABA
Mailing Address - State:MI
Mailing Address - Zip Code:49829-1300
Mailing Address - Country:US
Mailing Address - Phone:906-786-5707
Mailing Address - Fax:
Practice Address - Street 1:6412 N 8TH ST
Practice Address - Street 2:
Practice Address - City:WELLS
Practice Address - State:MI
Practice Address - Zip Code:49894-9735
Practice Address - Country:US
Practice Address - Phone:906-450-0475
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-13
Last Update Date:2022-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI26010003322255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer