Basic Information
| Provider Information | |||||||||
| NPI: | 1346450129 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LANDERS | ||||||||
| FirstName: | THEODORE | ||||||||
| MiddleName: | SCOTT | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | O.T.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 157 SANTA FE LN | ||||||||
| Address2: | |||||||||
| City: | WILLOW SPRINGS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604801624 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7084670467 | ||||||||
| FaxNumber: | 8153271614 | ||||||||
| Practice Location | |||||||||
| Address1: | 901 BIESTERFIELD RD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | ELK GROVE VILLAGE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600073392 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8474379889 | ||||||||
| FaxNumber: | 8473012829 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246Z00000X | Y | Technologists, Technicians & Other Technical Service Providers | Specialist/Technologist, Other |
No ID Information.