Healthcare Provider Details

I. General information

NPI: 1326891490
Provider Name (Legal Business Name): INFINITI RANDOLPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2024
Last Update Date: 04/09/2024
Certification Date: 04/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 UNIVERSAL CITY PLZ
UNIVERSAL CTY CA
91608-1002
US

IV. Provider business mailing address

519 8TH ST
ZOLFO SPRINGS FL
33890-5728
US

V. Phone/Fax

Practice location:
  • Phone: --
  • Fax:
Mailing address:
  • Phone: 863-864-0387
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number977368
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: