Healthcare Provider Details

I. General information

NPI: 1164723151
Provider Name (Legal Business Name): REBECCA RANDALL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2010
Last Update Date: 11/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7 MAVERICK ST
CHARLESTON SC
29403-4114
US

IV. Provider business mailing address

7 MAVERICK ST
CHARLESTON SC
29403-4114
US

V. Phone/Fax

Practice location:
  • Phone: 843-882-7115
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225000000X
TaxonomyOrthotic Fitter
License Number3976
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code247200000X
TaxonomyOther Technician
License NumberCFTS3976
License Number StateSC
# 3
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: