Provider Demographics
NPI:1073759338
Name:KINGSBURY RANDOLPH LLC
Entity Type:Organization
Organization Name:KINGSBURY RANDOLPH LLC
Other - Org Name:FOOT SOLUTIONS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:CAIN
Authorized Official - Suffix:
Authorized Official - Credentials:ABC C PED
Authorized Official - Phone:708-364-7463
Mailing Address - Street 1:15864 S LA GRANGE RD
Mailing Address - Street 2:SUITE D1C
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-5366
Mailing Address - Country:US
Mailing Address - Phone:708-364-7463
Mailing Address - Fax:
Practice Address - Street 1:15864 S LA GRANGE RD
Practice Address - Street 2:SUITE D1C
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-5366
Practice Address - Country:US
Practice Address - Phone:708-364-7463
Practice Address - Fax:708-364-1733
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-16
Last Update Date:2008-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier