Provider Demographics
NPI:1093252298
Name:RANDOLPH ASSISTED LIVING LLC
Entity Type:Organization
Organization Name:RANDOLPH ASSISTED LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MONALISA
Authorized Official - Middle Name:
Authorized Official - Last Name:RANDOLPH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-250-3048
Mailing Address - Street 1:12974 E ELGIN DR
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80239-4419
Mailing Address - Country:US
Mailing Address - Phone:719-250-3048
Mailing Address - Fax:303-375-0674
Practice Address - Street 1:12974 E ELGIN DR
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80239-4419
Practice Address - Country:US
Practice Address - Phone:719-250-3048
Practice Address - Fax:303-375-0674
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-25
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO23Q662372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes372600000XNursing Service Related ProvidersAdult CompanionGroup - Single Specialty