Healthcare Provider Details

I. General information

NPI: 1609378991
Provider Name (Legal Business Name): RANDOLPH DIABETES AND WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2018
Last Update Date: 05/12/2021
Certification Date: 05/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13047 W LINEBAUGH AVE STE 102
TAMPA FL
33626-4487
US

IV. Provider business mailing address

13047 W LINEBAUGH AVE STE 102
TAMPA FL
33626-4487
US

V. Phone/Fax

Practice location:
  • Phone: 813-475-6542
  • Fax: 813-475-6874
Mailing address:
  • Phone: 813-475-6542
  • Fax: 813-475-6874

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberARNP9318390
License Number StateFL

VIII. Authorized Official

Name: MS. KIMBERLY T RANDOLPH
Title or Position: OWNER/MANAGER
Credential: APRN-C
Phone: 813-846-7698