Basic Information
Provider Information | |||||||||
NPI: | 1972232353 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LANDIS | ||||||||
FirstName: | SAMANTHA | ||||||||
MiddleName: | GENE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PTA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1200 CORPORATE DR STE 400 | ||||||||
Address2: |   | ||||||||
City: | HOOVER | ||||||||
State: | AL | ||||||||
PostalCode: | 352425424 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4232387217 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1227 E 32ND ST STE 7 | ||||||||
Address2: |   | ||||||||
City: | JOPLIN | ||||||||
State: | MO | ||||||||
PostalCode: | 648042904 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4176247400 | ||||||||
FaxNumber: | 4176247403 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/09/2022 | ||||||||
LastUpdateDate: | 07/26/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/26/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 14-03954 | KS | N |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |   | 225100000X | 2022028528 | MO | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
No ID Information.