Healthcare Provider Details

I. General information

NPI: 1215660220
Provider Name (Legal Business Name): RACHEL RANDOLPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2022
Last Update Date: 07/07/2022
Certification Date: 05/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1360 E VENICE AVE
VENICE FL
34285-9066
US

IV. Provider business mailing address

1360 E VENICE AVE
VENICE FL
34285-9066
US

V. Phone/Fax

Practice location:
  • Phone: 941-488-2020
  • Fax:
Mailing address:
  • Phone: 941-488-2020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPC6127
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: