Healthcare Provider Details

I. General information

NPI: 1306946389
Provider Name (Legal Business Name): RANDALL LEWIS CRAIG PT ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 11/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

134 CHESTERFIELD VALLEY DR
CHESTERFIELD MO
63005-1161
US

IV. Provider business mailing address

600 OAKMONT LN STE 600C
WESTMONT IL
60559-5548
US

V. Phone/Fax

Practice location:
  • Phone: 636-812-0094
  • Fax: 636-812-0152
Mailing address:
  • Phone: 630-575-1980
  • Fax: 630-928-5080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberR1130
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: