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General NPI Number Information
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NPI Number | 1588833412
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Entity Type | Organization
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Legal Business Name | STEVE RANDLE
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Dates
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Enumeration Date | 02/25/2008
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Last Update Date | 02/01/2011
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Provider Practice Location Address
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Address Line | 307 MAIN ST S
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City | AMORY
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State | MS
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Zip | 38821-4219
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Country | US
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Telephone | 662-256-8481
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 475
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City | AMORY
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State | MS
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Zip | 38821-0475
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Country | US
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Telephone | 662-256-8481
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | STEVE RANDLE
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Credential | O.D.
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Telephone | 662-256-8481
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332H00000X
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Taxonomy Name | Eyewear Supplier
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License Number | 515
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License Number State | MS
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