Provider Demographics
NPI:1720507288
Name:ETHRIDGE, LANDON KEITH (PTA)
Entity Type:Individual
Prefix:
First Name:LANDON
Middle Name:KEITH
Last Name:ETHRIDGE
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:TN
Mailing Address - Zip Code:37012-2000
Mailing Address - Country:US
Mailing Address - Phone:1601-616-7917
Mailing Address - Fax:
Practice Address - Street 1:3131 TOM AUSTIN HWY
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:TN
Practice Address - Zip Code:37172-4801
Practice Address - Country:US
Practice Address - Phone:615-415-2010
Practice Address - Fax:615-634-3821
Is Sole Proprietor?:No
Enumeration Date:2017-09-15
Last Update Date:2017-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist