=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124870449
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RANDY J NEELY
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/02/2024
-----------------------------------------------------
Last Update Date | 04/02/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4473 COUNTY ROAD 140
-----------------------------------------------------
City | QUITMAN
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39355-9611
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-527-1238
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4473 COUNTY ROAD 140
-----------------------------------------------------
City | QUITMAN
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39355-9611
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-527-1238
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 227800000X
-----------------------------------------------------
Taxonomy Name | Certified Respiratory Therapist
-----------------------------------------------------
License Number | RCP5261
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 227800000X
-----------------------------------------------------
Taxonomy Name | Certified Respiratory Therapist
-----------------------------------------------------
License Number | RCP-5261
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------