MEDICARE: MARY RANDOLPH RN

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	163WA2000X	Administrator Registered Nurse	115016	CO

General Provider Information

NPI Number	:	1396005443
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY RANDOLPH RN

Provider Business Mailing Address
First Line	:	PO BOX 368
Second Line	:
City	:	DOVE CREEK
State	:	CO
Zip	:	81324-0368
Country	:	US
Telephone Number	:	970-677-2387
Fax Number	:	970-677-2948

Provider Business Practice Location Address
First Line	:	497 WEST 4TH STREET
Second Line	:
City	:	DOVE CREEK
State	:	CO
Zip	:	81324-0368
Country	:	US
Telephone Number	:	970-677-2387
Fax Number	:	970-677-2948

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

Provider Enumeration Date	:	05/23/2012
Last Update Date	:	05/23/2012

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