Provider Demographics
NPI:1588559322
Name:TILLEY, RANDY LEE
Entity type:Individual
Prefix:
First Name:RANDY
Middle Name:LEE
Last Name:TILLEY
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 1:163 MCGRAWS RD
Mailing Address - Street 2:
Mailing Address - City:MCGRAWS
Mailing Address - State:WV
Mailing Address - Zip Code:25875
Mailing Address - Country:US
Mailing Address - Phone:304-731-7009
Mailing Address - Fax:
Practice Address - Street 1:163 MCGRAWS RD
Practice Address - Street 2:
Practice Address - City:MCGRAWS
Practice Address - State:WV
Practice Address - Zip Code:25875
Practice Address - Country:US
Practice Address - Phone:304-731-7009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-11
Last Update Date:2025-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant