MEDICARE: RANDALL DAVID SCHROEDER

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	385HR2055X	Child Mental Illness Respite Care	1446377	AZ

General Provider Information

NPI Number	:	1982830691
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RANDALL DAVID SCHROEDER

Provider Business Mailing Address
First Line	:	3095 S PEAKS VIEW DRIVE
Second Line	:	POB 50901
City	:	PARKS
State	:	AZ
Zip	:	86018
Country	:	US
Telephone Number	:	928-607-9562
Fax Number	:

Provider Business Practice Location Address
First Line	:	3095 S PEAKS VIEW DR
Second Line	:	POB 50901
City	:	PARKS
State	:	AZ
Zip	:	86018-0901
Country	:	US
Telephone Number	:	928-607-9562
Fax Number	:

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

Provider Enumeration Date	:	06/09/2009
Last Update Date	:	06/09/2009

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