Provider Demographics
NPI:1568414803
Name:LAWRENCE, RANDALL WAYNE (PT)
Entity Type:Individual
Prefix:MR
First Name:RANDALL
Middle Name:WAYNE
Last Name:LAWRENCE
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 1:1810 E CLEVELAND ST
Mailing Address - Street 2:
Mailing Address - City:WEST FRANKFORT
Mailing Address - State:IL
Mailing Address - Zip Code:62896-3415
Mailing Address - Country:US
Mailing Address - Phone:618-932-2482
Mailing Address - Fax:
Practice Address - Street 1:1104 W MAIN ST
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:IL
Practice Address - Zip Code:62812-1565
Practice Address - Country:US
Practice Address - Phone:618-439-3399
Practice Address - Fax:618-439-4801
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist