MEDICARE: RANDY W DILLON MS,ATC,LAT, LMT, PES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	MSG010353	PA
2	2255A2300X	Athletic Trainer	RT003236	PA

General Provider Information

NPI Number	:	1043810021
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RANDY W DILLON MS,ATC,LAT, LMT, PES

Provider Business Mailing Address
First Line	:	917 OLD FERN HILL RD STE 500
Second Line	:
City	:	WEST CHESTER
State	:	PA
Zip	:	19380-4255
Country	:	US
Telephone Number	:	267-800-8031
Fax Number	:

Provider Business Practice Location Address
First Line	:	617C CHESTER PIKE
Second Line	:
City	:	PROSPECT PARK
State	:	PA
Zip	:	19076-1506
Country	:	US
Telephone Number	:	267-800-8031
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/28/2020
Last Update Date	:	10/28/2024

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