=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154048569
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RANDY OLUSHOLA DANIEL
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/26/2022
-----------------------------------------------------
Last Update Date | 10/26/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2612 HIDDEN HILL DR
-----------------------------------------------------
City | KILLEEN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76543-5751
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-440-8918
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2612 HIDDEN HILL DR
-----------------------------------------------------
City | KILLEEN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76543-5751
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-440-8918
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 343900000X
-----------------------------------------------------
Taxonomy Name | Non-emergency Medical Transport (VAN)
-----------------------------------------------------
License Number | 22394216
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------