Healthcare Provider Details

I. General information

NPI: 1013298686
Provider Name (Legal Business Name): MR. RANDY LEROY MARX
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2011
Last Update Date: 06/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 NWAKAMA ST STE 100
MARSHALL MN
56258-5530
US

IV. Provider business mailing address

1401 NWAKAMA ST STE 100
MARSHALL MN
56258-5530
US

V. Phone/Fax

Practice location:
  • Phone: 507-337-4500
  • Fax: 507-337-4502
Mailing address:
  • Phone: 507-337-4500
  • Fax: 507-337-4502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number2612
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: