Healthcare Provider Details

I. General information

NPI: 1003885070
Provider Name (Legal Business Name): RANDY HENKELS ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 E COLLEGE AVE
EUREKA IL
61530-1562
US

IV. Provider business mailing address

1905 CRESTMOOR COVE CC CT
NORMAL IL
61761-5352
US

V. Phone/Fax

Practice location:
  • Phone: 309-467-6378
  • Fax:
Mailing address:
  • Phone: 309-467-6378
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number96001189
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: