Healthcare Provider Details

I. General information

NPI: 1407301336
Provider Name (Legal Business Name): AVIS RANDLE MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2016
Last Update Date: 05/27/2025
Certification Date: 05/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

259 E 115TH ST
CHICAGO IL
60628-5014
US

IV. Provider business mailing address

259 E 115TH ST
CHICAGO IL
60628-5014
US

V. Phone/Fax

Practice location:
  • Phone: 313-585-6084
  • Fax:
Mailing address:
  • Phone: 313-585-6084
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: