Provider Demographics
NPI:1457461915
Name:VILLARD, RANDY W (PT)
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:W
Last Name:VILLARD
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 1:3705 LAKEVIEW PKWY STE 105
Mailing Address - Street 2:
Mailing Address - City:ROWLETT
Mailing Address - State:TX
Mailing Address - Zip Code:75088-4178
Mailing Address - Country:US
Mailing Address - Phone:469-443-0458
Mailing Address - Fax:469-573-6918
Practice Address - Street 1:3705 LAKEVIEW PKWY STE 105
Practice Address - Street 2:
Practice Address - City:ROWLETT
Practice Address - State:TX
Practice Address - Zip Code:75088-4178
Practice Address - Country:US
Practice Address - Phone:469-443-0458
Practice Address - Fax:469-573-6918
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2018-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1124683225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0009BYMedicare PIN