Provider Demographics
NPI:1720121056
Name:RANDALL, BROOKE L (ATC, CMT)
Entity Type:Individual
Prefix:MRS
First Name:BROOKE
Middle Name:L
Last Name:RANDALL
Suffix:
Gender:F
Credentials:ATC, CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6120 STADIUM DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009-3022
Mailing Address - Country:US
Mailing Address - Phone:269-372-8555
Mailing Address - Fax:
Practice Address - Street 1:6120 STADIUM DR
Practice Address - Street 2:SUITE 100
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49009-3022
Practice Address - Country:US
Practice Address - Phone:269-372-8555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2012-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer