Healthcare Provider Details

I. General information

NPI: 1134632532
Provider Name (Legal Business Name): AMBER RANDALL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2017
Last Update Date: 11/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3492 LAKE DR SE
GRAND RAPIDS MI
49546-4338
US

IV. Provider business mailing address

3492 LAKE DR SE
GRAND RAPIDS MI
49546-4338
US

V. Phone/Fax

Practice location:
  • Phone: 616-248-5100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: