Provider Demographics
NPI:1235584525
Name:RANDOLPH, QUINTEN
Entity Type:Individual
Prefix:
First Name:QUINTEN
Middle Name:
Last Name:RANDOLPH
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 1:206 EMERLING DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63121-1022
Mailing Address - Country:US
Mailing Address - Phone:314-566-7109
Mailing Address - Fax:
Practice Address - Street 1:206 EMERLING DR
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63121-1022
Practice Address - Country:US
Practice Address - Phone:314-566-7109
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-25
Last Update Date:2016-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOLC001476161171WV0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WV0202XOther Service ProvidersContractorVehicle Modifications