1164169371 NPI number — RANDOLPH'S FAMILY HEALTH AND WELLNESS

Table of content: (NPI 1164169371)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164169371 NPI number — RANDOLPH'S FAMILY HEALTH AND WELLNESS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RANDOLPH'S FAMILY HEALTH AND WELLNESS
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1164169371
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/22/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12596 US HIGHWAY 98 N
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKELAND
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33809-1089
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
863-860-4500
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3037 LAKELAND HILLS BLVD STE 7A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKELAND
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33805-2225
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
863-860-4500
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/18/2022

Additional Information

Authorized Official

Authorized Official Last Name:
RANDOLPH
Authorized Official First Name:
AMANDA
Authorized Official Middle Name:
LUCILLE
Authorized Official Title or Position:
NURSE PRACTITIONER
Authorized Official Telephone Number:
863-333-0032

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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