1720110406 NPI number — MR. RANDALL WAYNE HOFFMAN LADC

Table of content: MR. RANDALL WAYNE HOFFMAN LADC (NPI 1720110406)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720110406 NPI number — MR. RANDALL WAYNE HOFFMAN LADC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HOFFMAN
Provider First Name:
RANDALL
Provider Middle Name:
WAYNE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
LADC
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:
1720110406
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
217 PLUM ST
Provider Second Line Business Mailing Address:
ARMORY CENTER SUITE 220
Provider Business Mailing Address City Name:
RED WING
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55066-2351
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-388-2090
Provider Business Mailing Address Fax Number:
351-388-2129

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
124 MAIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PRESTON
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55965
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
507-765-2505
Provider Business Practice Location Address Fax Number:
507-765-2252
Provider Enumeration Date:
03/09/2007

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: 101YA0400X , with the licence number:  301276 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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