Healthcare Provider Details

I. General information

NPI: 1861628075
Provider Name (Legal Business Name): MR. RANDALL LYKENS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2009
Last Update Date: 06/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 N TILLOTSON AVE
MUNCIE IN
47304-3988
US

IV. Provider business mailing address

240 N TILLOTSON AVE
MUNCIE IN
47304-3988
US

V. Phone/Fax

Practice location:
  • Phone: 765-288-1928
  • Fax: 765-741-0310
Mailing address:
  • Phone: 765-288-1928
  • Fax: 765-741-0310

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number33000360A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: