1053561860 NPI number — MRS. RETHA JENNIFER RANDALL APN

Table of content: MRS. RETHA JENNIFER RANDALL APN (NPI 1053561860)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053561860 NPI number — MRS. RETHA JENNIFER RANDALL APN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RANDALL
Provider First Name:
RETHA
Provider Middle Name:
JENNIFER
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
APN
Provider Gender Code:
F

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:
1053561860
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/01/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
316 LAKEVIEW DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLLINGSWOOD
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08108-3029
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
856-869-7965
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1012 LAUREL OAK RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VOORHEES
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08043-3505
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
856-435-7502
Provider Business Practice Location Address Fax Number:
856-627-2183
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: 363LP0200X , with the licence number:  26NN10600900 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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