Healthcare Provider Details

I. General information

NPI: 1679606131
Provider Name (Legal Business Name): RANDALL LEE WRIGHT LAT,ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 CHRYSLER DR
BELVIDERE IL
61008-6006
US

IV. Provider business mailing address

10009 SARA DR
ROSCOE IL
61073-8598
US

V. Phone/Fax

Practice location:
  • Phone: 815-547-2440
  • Fax: 815-547-2458
Mailing address:
  • Phone: 815-623-9024
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: