Healthcare Provider Details

I. General information

NPI: 1386906436
Provider Name (Legal Business Name): JOHN CARL RANDALL LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2012
Last Update Date: 06/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2273 S VISTA AVE STE 190
BOISE ID
83705-7341
US

IV. Provider business mailing address

3132 W IRENE ST
BOISE ID
83703-5874
US

V. Phone/Fax

Practice location:
  • Phone: 208-343-2737
  • Fax: 208-342-3238
Mailing address:
  • Phone: 315-278-6609
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLMSW-32190
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: