Healthcare Provider Details

I. General information

NPI: 1821478827
Provider Name (Legal Business Name): RANDI M BOLEMAN PHD, RD, LD, CSSD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2015
Last Update Date: 07/09/2024
Certification Date: 06/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2520 ROBINHOOD ST APT 403
HOUSTON TX
77005-2550
US

IV. Provider business mailing address

2520 ROBINHOOD ST APT 403
HOUSTON TX
77005-2550
US

V. Phone/Fax

Practice location:
  • Phone: 979-255-7673
  • Fax:
Mailing address:
  • Phone: 979-255-7673
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1501X
TaxonomySports Dietetics Nutrition Registered Dietitian
License Number950484
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDT80230
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number950484
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: