=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093252298
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RANDOLPH ASSISTED LIVING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/25/2017
-----------------------------------------------------
Last Update Date | 01/25/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12974 E ELGIN DR
-----------------------------------------------------
City | DENVER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80239-4419
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-250-3048
-----------------------------------------------------
Fax | 303-375-0674
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12974 E ELGIN DR
-----------------------------------------------------
City | DENVER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80239-4419
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-250-3048
-----------------------------------------------------
Fax | 303-375-0674
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER ADMINISTRATOR
-----------------------------------------------------
Name | MONALISA RANDOLPH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 719-250-3048
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 372600000X
-----------------------------------------------------
Taxonomy Name | Adult Companion
-----------------------------------------------------
License Number | 23Q662
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------