=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609517499
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HEATHER RANDALL LMT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/05/2022
-----------------------------------------------------
Last Update Date | 04/05/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1013 LAKE ST STE 100
-----------------------------------------------------
City | SANDPOINT
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83864-5002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-597-7597
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 34 SKYRANCH DR
-----------------------------------------------------
City | SANDPOINT
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83864-7524
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-567-9768
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | MAS-4722
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------