Healthcare Provider Details

I. General information

NPI: 1114261526
Provider Name (Legal Business Name): BRETT RANDALL IDMT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/26/2012
Last Update Date: 07/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 W HILL BLVD
CHARLESTON AFB SC
29404-4704
US

IV. Provider business mailing address

204 W HILL BLVD
CHARLESTON AFB SC
29404-4704
US

V. Phone/Fax

Practice location:
  • Phone: 843-963-6880
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1003X
TaxonomyIndependent Duty Medical Technicians
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: