MEDICARE: JOSH RANDALL

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	247200000X	Other Technician		ND

General Provider Information

NPI Number	:	1407307150
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOSH RANDALL

Provider Business Mailing Address
First Line	:	891 BELSLY BLVD
Second Line	:
City	:	MOORHEAD
State	:	MN
Zip	:	56560-5055
Country	:	US
Telephone Number	:	218-287-4338
Fax Number	:	218-287-5928

Provider Business Practice Location Address
First Line	:	1126 WESTRAC DR S
Second Line	:
City	:	FARGO
State	:	ND
Zip	:	58103-2342
Country	:	US
Telephone Number	:	701-412-2973
Fax Number	:	701-237-4407

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

Provider Enumeration Date	:	10/18/2016
Last Update Date	:	10/18/2016

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Directions to “ JOSH RANDALL ” Practice Location

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