MEDICARE: LATAVIA RANDOLPH

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	172A00000X	Driver
2	343900000X	Non-emergency Medical Transport (VAN)		AL

General Provider Information

NPI Number	:	1194288811
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LATAVIA RANDOLPH

Provider Business Mailing Address
First Line	:	2703 BEVERLY P WASHINGTON ST
Second Line	:
City	:	PRICHARD
State	:	AL
Zip	:	36613-3449
Country	:	US
Telephone Number	:	251-458-3190
Fax Number	:

Provider Business Practice Location Address
First Line	:	2703 BEVERLY P WASHINGTON ST
Second Line	:
City	:	PRICHARD
State	:	AL
Zip	:	36613-3449
Country	:	US
Telephone Number	:	251-458-3190
Fax Number	:

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

Provider Enumeration Date	:	04/09/2019
Last Update Date	:	05/31/2019

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Directions to “ LATAVIA RANDOLPH ” Practice Location

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