MEDICARE: MR. NICHOLAS RANDALL

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	374U00000X	Home Health Aide		MO

General Provider Information

NPI Number	:	1457298713
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. NICHOLAS RANDALL

Provider Business Mailing Address
First Line	:	6619 BARR ST
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63121-3222
Country	:	US
Telephone Number	:	314-303-0587
Fax Number	:

Provider Business Practice Location Address
First Line	:	6619 BARR ST
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63121-3222
Country	:	US
Telephone Number	:	314-303-0587
Fax Number	:

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

Provider Enumeration Date	:	05/04/2026
Last Update Date	:	05/04/2026

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Directions to “ MR. NICHOLAS RANDALL ” Practice Location

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