MEDICARE: MRS. CRYSTAL K RANDAZZO

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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

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	:	1366773145
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CRYSTAL K RANDAZZO

Provider Business Mailing Address
First Line	:	721 S GEORGE NIGH EXPY
Second Line	:
City	:	MCALESTER
State	:	OK
Zip	:	74501-7400
Country	:	US
Telephone Number	:	918-424-3283
Fax Number	:

Provider Business Practice Location Address
First Line	:	721 S GEORGE NIGH EXPY
Second Line	:
City	:	MCALESTER
State	:	OK
Zip	:	74501-7400
Country	:	US
Telephone Number	:	918-424-3283
Fax Number	:

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

Provider Enumeration Date	:	01/19/2010
Last Update Date	:	01/19/2010

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