Healthcare Provider Details

I. General information

NPI: 1376907048
Provider Name (Legal Business Name): RANDY MCLAURIN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2016
Last Update Date: 04/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

681 CLARKSON AVE
BROOKLYN NY
11203-2125
US

IV. Provider business mailing address

789 SAINT MARKS AVE APT 22A
BROOKLYN NY
11213-1453
US

V. Phone/Fax

Practice location:
  • Phone: 718-221-7430
  • Fax:
Mailing address:
  • Phone: 718-221-6762
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: