Provider Demographics
NPI:1215546064
Name:CASEY, RANDY DALE (PT)
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:DALE
Last Name:CASEY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3000 MAGNOLIA WAY
Mailing Address - Street 2:
Mailing Address - City:PUNTA GORDA
Mailing Address - State:FL
Mailing Address - Zip Code:33950-7030
Mailing Address - Country:US
Mailing Address - Phone:941-661-8062
Mailing Address - Fax:
Practice Address - Street 1:3000 MAGNOLIA WAY
Practice Address - Street 2:
Practice Address - City:PUNTA GORDA
Practice Address - State:FL
Practice Address - Zip Code:33950-7030
Practice Address - Country:US
Practice Address - Phone:941-661-8062
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-28
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11278225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist