Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1700X | Ocularist | 203.000116 | IL |
NPI | 1124060074 |
---|---|
Provider Name | Mr. Randy L Light |
First Address | Peoria, IL 61614-8508 |
Second Address | Peoria, IL 61614-8508 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/06/2006 |
Last Update Date | 03/07/2009 |