Healthcare Provider Details

I. General information

NPI: 1033361506
Provider Name (Legal Business Name): RANDY EUGENE LLOYD LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/16/2008
Last Update Date: 10/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14602 W SOUTHPORT RD
BRIMFIELD IL
61517-9372
US

IV. Provider business mailing address

14602 W SOUTHPORT RD
BRIMFIELD IL
61517-9372
US

V. Phone/Fax

Practice location:
  • Phone: 309-446-3974
  • Fax:
Mailing address:
  • Phone: 309-446-3974
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number227005116
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: