1023268968 NPI number — SANDRA RENAE RANDOLPH AUD

Table of content: SANDRA RENAE RANDOLPH AUD (NPI 1023268968)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023268968 NPI number — SANDRA RENAE RANDOLPH AUD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RANDOLPH
Provider First Name:
SANDRA
Provider Middle Name:
RENAE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
AUD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
THOMPSON
Provider Other First Name:
SANDRA
Provider Other Middle Name:
RENAE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
AUD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1023268968
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/21/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1900 WOODLAND DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COOS BAY
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97420-2045
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-267-5151
Provider Business Mailing Address Fax Number:
541-266-4595

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1900 WOODLAND DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COOS BAY
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97420-2045
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-267-5151
Provider Business Practice Location Address Fax Number:
541-266-4595
Provider Enumeration Date:
09/29/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 231H00000X , with the licence number:  23138 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 930635514 . This is a "NBMC GROUP TAX ID FOR BILLING" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: R0000WFBTV . This is a "NBMC GROUP MEDICARE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 1407812365 . This is a "NBMC MAIN GROUP NPI" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 161133 . This is a "NBMC GROUP MEDICAID-DMAP" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 500600529 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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