Provider Demographics
NPI:1023250826
Name:RANDOLPH SPORTS PHYSICAL THERAPY, INC.
Entity type:Organization
Organization Name:RANDOLPH SPORTS PHYSICAL THERAPY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:A
Authorized Official - Last Name:RANDOLPH
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:708-359-6255
Mailing Address - Street 1:1321 PRAIRIE ESTATE DR
Mailing Address - Street 2:
Mailing Address - City:NEW LENOX
Mailing Address - State:IL
Mailing Address - Zip Code:60451-2837
Mailing Address - Country:US
Mailing Address - Phone:815-462-7778
Mailing Address - Fax:
Practice Address - Street 1:1321 PRAIRIE ESTATE DR
Practice Address - Street 2:
Practice Address - City:NEW LENOX
Practice Address - State:IL
Practice Address - Zip Code:60451-2837
Practice Address - Country:US
Practice Address - Phone:815-462-7778
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-26
Last Update Date:2013-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070012723225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty