Provider Demographics
NPI:1225410327
Name:RANDOLPH, MERINDA DOREEN (SERVICE FACIL)
Entity Type:Individual
Prefix:MRS
First Name:MERINDA
Middle Name:DOREEN
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:SERVICE FACIL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5113 S JESSUP RD
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23832-8238
Mailing Address - Country:US
Mailing Address - Phone:804-908-7687
Mailing Address - Fax:888-745-0938
Practice Address - Street 1:5113 S JESSUP RD
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23832-8238
Practice Address - Country:US
Practice Address - Phone:804-908-7687
Practice Address - Fax:888-745-0938
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-24
Last Update Date:2015-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA471373561251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0173936938Medicaid