=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053651794
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RANDY'S HOME CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/17/2013
-----------------------------------------------------
Last Update Date | 02/17/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16201 SW 288TH ST
-----------------------------------------------------
City | HOMESTEAD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33033-1018
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-477-2935
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16201 SW 288TH ST
-----------------------------------------------------
City | HOMESTEAD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33033-1018
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-477-2935
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE PRESIDENT
-----------------------------------------------------
Name | MRS. ELDA ISERN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 786-477-2935
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | 12161
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------