Provider Demographics
NPI:1841680584
Name:JOHNSON, RANDEL
Entity type:Individual
Prefix:MR
First Name:RANDEL
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2615 THREE OAKS RD
Mailing Address - Street 2:SUITE 2B
Mailing Address - City:CARY
Mailing Address - State:IL
Mailing Address - Zip Code:60013-6127
Mailing Address - Country:US
Mailing Address - Phone:815-260-4559
Mailing Address - Fax:847-639-4192
Practice Address - Street 1:2615 THREE OAKS RD
Practice Address - Street 2:SUITE 2B
Practice Address - City:CARY
Practice Address - State:IL
Practice Address - Zip Code:60013-6127
Practice Address - Country:US
Practice Address - Phone:815-260-4559
Practice Address - Fax:847-639-4192
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-03
Last Update Date:2015-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227.001783173C00000X, 225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No173C00000XOther Service ProvidersReflexologist