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General NPI Number Information
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NPI Number | 1679886675
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Entity Type | Individual
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Provider Name | BLAKE WILLIAM RANDLES D.C.
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Gender | Male
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Dates
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Enumeration Date | 07/19/2010
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Last Update Date | 04/07/2025
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Provider Practice Location Address
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Address Line | 20733 N BROAD ST
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City | CARLINVILLE
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State | IL
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Zip | 62626-3710
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Country | US
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Telephone | 217-854-3141
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Fax |
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Provider Business Mailing Address
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Address Line | 1210 WASHINGTON ST
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City | HIGHLAND
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State | IL
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Zip | 62249-1925
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Country | US
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Telephone | 186-544-5206
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Fax | 618-654-1063
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LG0600X
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Taxonomy Name | Gerontology Nurse Practitioner
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License Number | 209031892
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License Number State | IL
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