MEDICARE: RANDALL B RIGDON LLC

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	261QP2300X	Primary Care Clinic/Center	ME75248	FL

General Provider Information

NPI Number	:	1982892501
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RANDALL B RIGDON LLC

Provider Business Mailing Address
First Line	:	270 N SYKES CREEK PKWY
Second Line	:	SUITE 202
City	:	MERRITT ISLAND
State	:	FL
Zip	:	32953-3492
Country	:	US
Telephone Number	:	321-454-2468
Fax Number	:	321-454-2469

Provider Business Practice Location Address
First Line	:	270 N SYKES CREEK PKWY
Second Line	:	SUITE 202
City	:	MERRITT ISLAND
State	:	FL
Zip	:	32953-3492
Country	:	US
Telephone Number	:	321-454-2468
Fax Number	:	321-454-2469

Authorized Official
Title or Position	:	PHYSICIAN
Name	:	RANDALL B. RIGDON
Credential	:
Telephone Number	:	321-536-3634

Provider Enumeration Date	:	10/09/2007
Last Update Date	:	10/09/2007

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Directions to “RANDALL B RIGDON LLC ” Practice Location

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