Provider Demographics
NPI:1679886675
Name:RANDLES, BLAKE WILLIAM (DC)
Entity type:Individual
Prefix:DR
First Name:BLAKE
Middle Name:WILLIAM
Last Name:RANDLES
Suffix:
Gender:
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1210 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:IL
Mailing Address - Zip Code:62249-1925
Mailing Address - Country:US
Mailing Address - Phone:186-544-5206
Mailing Address - Fax:618-654-1063
Practice Address - Street 1:20733 N BROAD ST
Practice Address - Street 2:
Practice Address - City:CARLINVILLE
Practice Address - State:IL
Practice Address - Zip Code:62626-3710
Practice Address - Country:US
Practice Address - Phone:217-854-3141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-19
Last Update Date:2025-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209031892363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology