Provider Demographics
NPI:1093111213
Name:SIMMONS, RANDALL EUGENE
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:EUGENE
Last Name:SIMMONS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:318 ACE ST
Mailing Address - Street 2:
Mailing Address - City:HAUGHTON
Mailing Address - State:LA
Mailing Address - Zip Code:71037-8774
Mailing Address - Country:US
Mailing Address - Phone:318-423-0297
Mailing Address - Fax:
Practice Address - Street 1:2575 AIRLINE DR
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-5812
Practice Address - Country:US
Practice Address - Phone:318-746-7466
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-16
Last Update Date:2014-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA200422224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant