Healthcare Provider Details

I. General information

NPI: 1306814819
Provider Name (Legal Business Name): ERIN MICHELLE RANDALL MS,
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2006
Last Update Date: 09/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 LINDOW LN STE M
MARENGO IL
60152-9480
US

IV. Provider business mailing address

921 VILLAGE CT
MARENGO IL
60152-3638
US

V. Phone/Fax

Practice location:
  • Phone: 815-568-6511
  • Fax:
Mailing address:
  • Phone: 815-572-5001
  • 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: