Healthcare Provider Details

I. General information

NPI: 1124060074
Provider Name (Legal Business Name): RANDY L LIGHT B.C.O., B.A.D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 07/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1318 W CANDLETREE DR SUITE 3
PEORIA IL
61614-8508
US

IV. Provider business mailing address

1318 W CANDLETREE DR SUITE 3
PEORIA IL
61614-8508
US

V. Phone/Fax

Practice location:
  • Phone: 309-676-3663
  • Fax: 309-676-0359
Mailing address:
  • Phone: 309-676-3663
  • Fax: 309-676-0359

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1700X
TaxonomyOcularist
License Number203.000116
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: