Individual
MR. RANDALL GLENN BROOKS
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PT
Contact information
Practice address
3221 BEACON PKWY STE 100, GRANGER, IN 46530-7196
(574) 647-2930
(574) 647-2935
Mailing address
710 N NILES AVE, SOUTH BEND, IN 46617-1924
(574) 647-1610
(574) 237-6069
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
05002570A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
300024808
—
IN
01
—
IN3678023
MEDICARE PTAN
IN
Enumeration date
06/21/2006
Last updated
03/31/2021
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