1679606131 NPI number — MR. RANDALL LEE WRIGHT LAT,ATC

Table of content: MR. RANDALL LEE WRIGHT LAT,ATC (NPI 1679606131)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679606131 NPI number — MR. RANDALL LEE WRIGHT LAT,ATC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WRIGHT
Provider First Name:
RANDALL
Provider Middle Name:
LEE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
LAT,ATC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1679606131
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10009 SARA DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROSCOE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61073-8598
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-623-9024
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3000 CHRYSLER DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BELVIDERE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61008-6006
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-547-2440
Provider Business Practice Location Address Fax Number:
815-547-2458
Provider Enumeration Date:
03/13/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2255A2300X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2025 www.npivalidator.com