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General NPI Number Information
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NPI Number | 1760782726
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Entity Type | Individual
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Provider Name | MR. WAYNE GEORGE RANDALL
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Gender | Male
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Dates
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Enumeration Date | 10/25/2010
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Last Update Date | 10/25/2010
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Provider Practice Location Address
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Address Line | 364 N CENTRAL BLVD
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City | COQUILLE
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State | OR
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Zip | 97423-1244
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Country | US
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Telephone | 541-396-4283
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Fax | 541-396-7194
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Provider Business Mailing Address
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Address Line | 364 N CENTRAL BLVD
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City | COQUILLE
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State | OR
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Zip | 97423-1244
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Country | US
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Telephone | 541-396-4283
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Fax | 541-396-7194
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | HSP-P-10131631
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License Number State | OR
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