Provider Demographics
NPI:1124060074
Name:LIGHT, RANDY L (BCO, BADO)
Entity type:Individual
Prefix:MR
First Name:RANDY
Middle Name:L
Last Name:LIGHT
Suffix:
Gender:M
Credentials:BCO, BADO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1318 W CANDLETREE DR
Mailing Address - Street 2:SUITE 3
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-8508
Mailing Address - Country:US
Mailing Address - Phone:309-676-3663
Mailing Address - Fax:309-676-0359
Practice Address - Street 1:1318 W CANDLETREE DR
Practice Address - Street 2:SUITE 3
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-8508
Practice Address - Country:US
Practice Address - Phone:309-676-3663
Practice Address - Fax:309-676-0359
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2009-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL203.000116156FX1700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1700XEye and Vision Services ProvidersTechnician/TechnologistOcularist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1268070002Medicare ID - Type Unspecified
IL1268070001Medicare NSC
AR1268070001Medicare NSC
MO1268070002Medicare NSC