Healthcare Provider Details

I. General information

NPI: 1255722989
Provider Name (Legal Business Name): RANDALL FLYNT MDIV
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/17/2015
Last Update Date: 02/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 EAGLERIDGE BLVD
PUEBLO CO
81008-2193
US

IV. Provider business mailing address

805 EAGLERIDGE BLVD
PUEBLO CO
81008-2193
US

V. Phone/Fax

Practice location:
  • Phone: 719-287-6282
  • Fax:
Mailing address:
  • Phone: 719-287-6282
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: