Provider Demographics
NPI:1598975203
Name:TOLLE, RANDY (ATC)
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:
Last Name:TOLLE
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1504 BERRY AVE
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:KS
Mailing Address - Zip Code:67114-1415
Mailing Address - Country:US
Mailing Address - Phone:316-283-9411
Mailing Address - Fax:
Practice Address - Street 1:900 W 12TH ST
Practice Address - Street 2:NEWTON HIGH SCHOOL
Practice Address - City:NEWTON
Practice Address - State:KS
Practice Address - Zip Code:67114-1451
Practice Address - Country:US
Practice Address - Phone:316-284-6280
Practice Address - Fax:316-284-6288
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS24-000252255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer