Healthcare Provider Details

I. General information

NPI: 1982920054
Provider Name (Legal Business Name): BOB RANDALL GROUNDS CASEMANAGER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/14/2010
Last Update Date: 04/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4400 N LINCOLN BLVD
OKLAHOMA CITY OK
73105-5104
US

IV. Provider business mailing address

4400 N LINCOLN BLVD
OKLAHOMA CITY OK
73105-5104
US

V. Phone/Fax

Practice location:
  • Phone: 405-425-0394
  • Fax: 405-425-0313
Mailing address:
  • Phone: 405-425-0394
  • Fax: 405-425-0313

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: