Healthcare Provider Details

I. General information

NPI: 1477922011
Provider Name (Legal Business Name): RANDYS MOM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2015
Last Update Date: 09/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 KEISLER DR STE 102
CARY NC
27518-7097
US

IV. Provider business mailing address

515 KEISLER DR STE 102
CARY NC
27518-7097
US

V. Phone/Fax

Practice location:
  • Phone: 919-757-6844
  • Fax: 919-230-2510
Mailing address:
  • Phone: 919-757-6844
  • Fax: 919-230-2510

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number
License Number State

VIII. Authorized Official

Name: JULIA SIMMONS
Title or Position: OWNER
Credential:
Phone: 919-757-6844