MEDICARE: MR. JEFFREY DWAYNE RANDALL MPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1376688796
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JEFFREY DWAYNE RANDALL MPC

Provider Business Mailing Address
First Line	:	501 HIGHWAY 90 E
Second Line	:
City	:	LITTLE RIVER
State	:	SC
Zip	:	29566
Country	:	US
Telephone Number	:	803-422-7231
Fax Number	:

Provider Business Practice Location Address
First Line	:	501 HIGHWAY 90 E
Second Line	:
City	:	LITTLE RIVER
State	:	SC
Zip	:	29566-9261
Country	:	US
Telephone Number	:	803-422-7231
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/21/2007
Last Update Date	:	09/18/2014

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