=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376705293
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LUKE A RANDALL O.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/01/2008
-----------------------------------------------------
Last Update Date | 03/15/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1540 W CAYUSE CREEK DR
-----------------------------------------------------
City | MERIDIAN
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83646-4795
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-258-6200
-----------------------------------------------------
Fax | 208-258-6204
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1540 W CAYUSE CREEK DR
-----------------------------------------------------
City | MERIDIAN
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83646-4795
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-258-6200
-----------------------------------------------------
Fax | 208-258-6204
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | ODP-100164
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------