Healthcare Provider Details

I. General information

NPI: 1700423902
Provider Name (Legal Business Name): RANDY BLAND
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/06/2019
Last Update Date: 06/29/2021
Certification Date: 06/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14047 W MONTE VISTA RD
GOODYEAR AZ
85395
US

IV. Provider business mailing address

INTERMOUNTAIN CENTERS FOR HUMAN DEVELOPMENT INC. PO BOX 86537
TUCSON AZ
85754-6537
US

V. Phone/Fax

Practice location:
  • Phone: 480-334-2092
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code385HR2055X
TaxonomyChild Mental Illness Respite Care
License Number10126301
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: