1508135625 NPI number — RANDALL ALAN ANDERSON LPE-I

Table of content: RANDALL ALAN ANDERSON LPE-I (NPI 1508135625)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508135625 NPI number — RANDALL ALAN ANDERSON LPE-I

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ANDERSON
Provider First Name:
RANDALL
Provider Middle Name:
ALAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LPE-I
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1508135625
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/21/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2400 S 48TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRINGDALE
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72762-6683
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-750-2020
Provider Business Mailing Address Fax Number:
479-750-4843

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
110 SKYLINE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RUSSELLVILLE
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72801-3362
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-968-1298
Provider Business Practice Location Address Fax Number:
479-968-6053
Provider Enumeration Date:
12/19/2011

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: 102L00000X , with the licence number:  88-12EI , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TC1900X , with the licence number: 88-12EI , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 228376719 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".