Provider Demographics
NPI:1114132214
Name:MILLER, RANDAL W (PTA)
Entity Type:Individual
Prefix:MR
First Name:RANDAL
Middle Name:W
Last Name:MILLER
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 STAHLHUT DR
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:IL
Mailing Address - Zip Code:62656-5066
Mailing Address - Country:US
Mailing Address - Phone:217-605-5500
Mailing Address - Fax:217-732-3101
Practice Address - Street 1:200 STAHLHUT DR
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:IL
Practice Address - Zip Code:62656-5066
Practice Address - Country:US
Practice Address - Phone:217-605-5500
Practice Address - Fax:217-732-3101
Is Sole Proprietor?:No
Enumeration Date:2007-05-11
Last Update Date:2012-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL60-002812225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant