MEDICARE: RHETT LEELAND RANDALL PT

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	225100000X	Physical Therapist	4190	OR

General Provider Information

NPI Number	:	1841466216
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RHETT LEELAND RANDALL PT

Provider Business Mailing Address
First Line	:	540 S MAIN ST
Second Line	:
City	:	MOUNT ANGEL
State	:	OR
Zip	:	97362-9540
Country	:	US
Telephone Number	:	503-845-6841
Fax Number	:	503-845-9229

Provider Business Practice Location Address
First Line	:	540 S MAIN ST
Second Line	:
City	:	MOUNT ANGEL
State	:	OR
Zip	:	97362-9540
Country	:	US
Telephone Number	:	503-845-6841
Fax Number	:	503-845-9229

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

Provider Enumeration Date	:	05/05/2008
Last Update Date	:	05/05/2008

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Directions to “ RHETT LEELAND RANDALL PT” Practice Location

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