Provider Demographics
NPI:1326891490
Name:RANDOLPH, INFINITI
Entity Type:Individual
Prefix:
First Name:INFINITI
Middle Name:
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:519 8TH ST
Mailing Address - Street 2:
Mailing Address - City:ZOLFO SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33890-5728
Mailing Address - Country:US
Mailing Address - Phone:863-864-0387
Mailing Address - Fax:
Practice Address - Street 1:100 UNIVERSAL CITY PLZ
Practice Address - Street 2:
Practice Address - City:UNIVERSAL CTY
Practice Address - State:CA
Practice Address - Zip Code:91608-1002
Practice Address - Country:US
Practice Address - Phone:000-000-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-09
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL977368106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician