Provider Demographics
NPI:1003885070
Name:HENKELS, RANDY (ATC)
Entity Type:Individual
Prefix:MR
First Name:RANDY
Middle Name:
Last Name:HENKELS
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1905 CRESTMOOR COVE CC CT
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-5352
Mailing Address - Country:US
Mailing Address - Phone:309-467-6378
Mailing Address - Fax:
Practice Address - Street 1:300 E COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:IL
Practice Address - Zip Code:61530-1562
Practice Address - Country:US
Practice Address - Phone:309-467-6378
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL96001189174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist