Provider Demographics
NPI:1164473237
Name:PAYNE, RANDALL L
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:L
Last Name:PAYNE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 LAKEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:WORDEN
Mailing Address - State:IL
Mailing Address - Zip Code:62097-1282
Mailing Address - Country:US
Mailing Address - Phone:618-459-7142
Mailing Address - Fax:
Practice Address - Street 1:5 LAKEVIEW DR
Practice Address - Street 2:
Practice Address - City:WORDEN
Practice Address - State:IL
Practice Address - Zip Code:62097-1282
Practice Address - Country:US
Practice Address - Phone:618-459-7142
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant