Provider Demographics
NPI:1215325931
Name:LILLARD, RANDY JR
Entity type:Individual
Prefix:MR
First Name:RANDY
Middle Name:
Last Name:LILLARD
Suffix:JR
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 1:14531 OLD NASHVILLE HWY
Mailing Address - Street 2:APT. 6106
Mailing Address - City:SMYRNA
Mailing Address - State:TN
Mailing Address - Zip Code:37167-6567
Mailing Address - Country:US
Mailing Address - Phone:217-597-5089
Mailing Address - Fax:
Practice Address - Street 1:620 GALLATIN PIKE S
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:TN
Practice Address - Zip Code:37115-4013
Practice Address - Country:US
Practice Address - Phone:615-460-4300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-05
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator