Healthcare Provider Details

I. General information

NPI: 1194288811
Provider Name (Legal Business Name): LATAVIA RANDOLPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: NET RUNS LLC

II. Dates (important events)

Enumeration Date: 04/09/2019
Last Update Date: 05/31/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2703 BEVERLY P WASHINGTON ST
PRICHARD AL
36613-3449
US

IV. Provider business mailing address

2703 BEVERLY P WASHINGTON ST
PRICHARD AL
36613-3449
US

V. Phone/Fax

Practice location:
  • Phone: 251-458-3190
  • Fax:
Mailing address:
  • Phone: 251-458-3190
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: