Healthcare Provider Details

I. General information

NPI: 1689808396
Provider Name (Legal Business Name): RANDALL EUGENE LAKES RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2009
Last Update Date: 05/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 E APPLE ST SUITE 5250
DAYTON OH
45409-2939
US

IV. Provider business mailing address

30 E APPLE ST SUITE 5250
DAYTON OH
45409-2939
US

V. Phone/Fax

Practice location:
  • Phone: 937-208-7723
  • Fax: 937-208-3855
Mailing address:
  • Phone: 937-208-7723
  • Fax: 937-208-3855

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0000X
TaxonomyPain Management Registered Nurse
License NumberRN268482
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: