MEDICARE: MR. VAN MCKINLEY 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	374U00000X	Home Health Aide

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1306324306
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. VAN MCKINLEY RANDOLPH

Provider Business Mailing Address
First Line	:	831 8TH ST NE
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20002-3616
Country	:	US
Telephone Number	:	202-577-3093
Fax Number	:

Provider Business Practice Location Address
First Line	:	1501 FORT DAVIS ST SE
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20020-6025
Country	:	US
Telephone Number	:	202-808-9369
Fax Number	:

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

Provider Enumeration Date	:	08/01/2018
Last Update Date	:	08/01/2018

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