Healthcare Provider Details

I. General information

NPI: 1174432108
Provider Name (Legal Business Name): RANDY HARRIS LVN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/04/2026
Last Update Date: 09/04/2026
Certification Date: 09/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 21ST ST
OAKLAND CA
94612-1605
US

IV. Provider business mailing address

525 21ST ST
OAKLAND CA
94612-1605
US

V. Phone/Fax

Practice location:
  • Phone: 510-587-3413
  • Fax:
Mailing address:
  • Phone: 510-587-3413
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License NumberVN220563
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: