MEDICARE: ASHLIE 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	225400000X	Rehabilitation Practitioner

General Provider Information

NPI Number	:	1396103776
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ASHLIE RANDOLPH

Provider Business Mailing Address
First Line	:	3053 W CRAIG RD
Second Line	:	#192
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89032-5106
Country	:	US
Telephone Number	:	702-461-1621
Fax Number	:	702-982-3103

Provider Business Practice Location Address
First Line	:	3053 W CRAIG RD
Second Line	:	#192
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89032-5106
Country	:	US
Telephone Number	:	702-461-1621
Fax Number	:	702-982-3103

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

Provider Enumeration Date	:	02/01/2016
Last Update Date	:	02/01/2016

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Directions to “ ASHLIE RANDOLPH ” Practice Location

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