Healthcare Provider Details

I. General information

NPI: 1588643167
Provider Name (Legal Business Name): RANDALL LEE JAMES OTR
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PSC 827, BOX 20
FPO ITALY
AE
US

IV. Provider business mailing address

PSC 827, BOX 20
FPO ITALY
AE
US

V. Phone/Fax

Practice location:
  • Phone: 81-811-4676
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1003X
TaxonomyIndependent Duty Medical Technicians
License Number100742
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: