MEDICARE: RANDALL W RUTHERFORD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	LIAC-155415	AZ

General Provider Information

NPI Number	:	1053242164
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RANDALL W RUTHERFORD

Provider Business Mailing Address
First Line	:	4109 E SUNRISE DR
Second Line	:	APT 1504
City	:	TUCSON
State	:	AZ
Zip	:	85718
Country	:	US
Telephone Number	:	520-268-4609
Fax Number	:

Provider Business Practice Location Address
First Line	:	2030 E SPEEDWAY BLVD STE 118
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85719-4750
Country	:	US
Telephone Number	:	520-268-4609
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/27/2026
Last Update Date	:	05/27/2026

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Directions to “ RANDALL W RUTHERFORD ” Practice Location

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