Provider Demographics
NPI:1346540382
Name:LOVE, RANDY W (CST/CFA)
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:W
Last Name:LOVE
Suffix:
Gender:M
Credentials:CST/CFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4004 14TH AVE E
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34208-9013
Mailing Address - Country:US
Mailing Address - Phone:941-951-9767
Mailing Address - Fax:760-731-0414
Practice Address - Street 1:4004 14TH AVE E
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34208-9013
Practice Address - Country:US
Practice Address - Phone:941-951-9767
Practice Address - Fax:760-731-0414
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-25
Last Update Date:2010-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
No246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist