Provider Demographics
NPI:1205828381
Name:RANDOLPH MEDICAL PLUS LLC
Entity Type:Organization
Organization Name:RANDOLPH MEDICAL PLUS LLC
Other - Org Name:RANDOLPH SEATING AND MOBILITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER, ATP
Authorized Official - Prefix:MR
Authorized Official - First Name:KENTON
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:RANDOLPH
Authorized Official - Suffix:
Authorized Official - Credentials:ATP
Authorized Official - Phone:816-364-4357
Mailing Address - Street 1:PO BOX 1395
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64502-1395
Mailing Address - Country:US
Mailing Address - Phone:816-364-4357
Mailing Address - Fax:816-364-3165
Practice Address - Street 1:2303 S 22ND ST
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64503-2811
Practice Address - Country:US
Practice Address - Phone:816-364-4357
Practice Address - Fax:816-364-3165
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-16
Last Update Date:2016-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO623991205Medicaid
MO623991205Medicaid