Healthcare Provider Details

I. General information

NPI: 1518157551
Provider Name (Legal Business Name): MALCOM RANDALL VA MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2007
Last Update Date: 07/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 S.W ARCHER ROAD
GAINESVILLE FL
32608-1135
US

IV. Provider business mailing address

3800 S.W 34TH STREET APT. GG-334
GAINESVILLE FL
32608
US

V. Phone/Fax

Practice location:
  • Phone: 352-376-1611
  • Fax: 352-374-6113
Mailing address:
  • Phone: 352-367-4351
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code282NC0060X
TaxonomyCritical Access Hospital
License Number024871
License Number StatePR
# 2
Primary TaxonomyY
Taxonomy Code282NC0060X
TaxonomyCritical Access Hospital
License Number828464
License Number StateFL

VIII. Authorized Official

Name: MISS MIRIAM MACHADO-RODRIGUEZ
Title or Position: NURSE-BSN
Credential: RN-BSN
Phone: 352-376-1611