Provider Demographics
NPI:1093983025
Name:RANDY E WADDELL
Entity Type:Organization
Organization Name:RANDY E WADDELL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:E
Authorized Official - Last Name:WADDELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-765-2998
Mailing Address - Street 1:426 GREYBULL AVE
Mailing Address - Street 2:
Mailing Address - City:GREYBULL
Mailing Address - State:WY
Mailing Address - Zip Code:82426-2037
Mailing Address - Country:US
Mailing Address - Phone:307-765-2998
Mailing Address - Fax:307-765-2614
Practice Address - Street 1:426 GREYBULL AVE
Practice Address - Street 2:
Practice Address - City:GREYBULL
Practice Address - State:WY
Practice Address - Zip Code:82426-2037
Practice Address - Country:US
Practice Address - Phone:307-765-2998
Practice Address - Fax:307-765-2614
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-12
Last Update Date:2008-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY133T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY0738250001Medicare NSC