Provider Demographics
NPI:1679606131
Name:WRIGHT, RANDALL LEE (LAT,ATC)
Entity type:Individual
Prefix:MR
First Name:RANDALL
Middle Name:LEE
Last Name:WRIGHT
Suffix:
Gender:M
Credentials:LAT,ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10009 SARA DR
Mailing Address - Street 2:
Mailing Address - City:ROSCOE
Mailing Address - State:IL
Mailing Address - Zip Code:61073-8598
Mailing Address - Country:US
Mailing Address - Phone:815-623-9024
Mailing Address - Fax:
Practice Address - Street 1:3000 CHRYSLER DR
Practice Address - Street 2:
Practice Address - City:BELVIDERE
Practice Address - State:IL
Practice Address - Zip Code:61008-6006
Practice Address - Country:US
Practice Address - Phone:815-547-2440
Practice Address - Fax:815-547-2458
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer