Healthcare Provider Details

I. General information

NPI: 1598081101
Provider Name (Legal Business Name): RANDY ELLSWORTH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2010
Last Update Date: 04/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

126 S SEMORAN BLVD
ORLANDO FL
32807-3293
US

IV. Provider business mailing address

126 S SEMORAN BLVD
ORLANDO FL
32807-3293
US

V. Phone/Fax

Practice location:
  • Phone: 407-614-5977
  • Fax: 407-614-5979
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License NumberAS1070
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: