Healthcare Provider Details

I. General information

NPI: 1700829801
Provider Name (Legal Business Name): RANDELL GLENN HARRELL
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7761 PEPPER CIR WEST
JACKSONVILLE FL
32244
US

IV. Provider business mailing address

7761 PEPPER CIR WEST
JACKSONVILLE FL
32244
US

V. Phone/Fax

Practice location:
  • Phone: 904-777-9543
  • Fax: 904-777-9733
Mailing address:
  • Phone: 904-777-9543
  • Fax: 904-777-9733

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: