Provider Demographics
NPI:1598852139
Name:LANGLEY, RANDALL KEITH (RPT, OCS)
Entity Type:Individual
Prefix:MR
First Name:RANDALL
Middle Name:KEITH
Last Name:LANGLEY
Suffix:
Gender:M
Credentials:RPT, OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:457 S FITNESS PL
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-6568
Mailing Address - Country:US
Mailing Address - Phone:208-939-3332
Mailing Address - Fax:208-939-3338
Practice Address - Street 1:457 S FITNESS PL
Practice Address - Street 2:SUITE 100
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-6568
Practice Address - Country:US
Practice Address - Phone:208-939-3332
Practice Address - Fax:208-939-3338
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2008-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDRPT 655225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002779700Medicaid
650012139OtherRAILROAD MEDICARE
T4371OtherBLUE CROSS
000010009145OtherBLUE SHIELD
ID002779700Medicaid