Provider Demographics
NPI:1356072011
Name:RANDALL, THERESA
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:RANDALL
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 1:1201 KNOX AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH AUGUSTA
Mailing Address - State:SC
Mailing Address - Zip Code:29841-4056
Mailing Address - Country:US
Mailing Address - Phone:803-202-0182
Mailing Address - Fax:803-202-0275
Practice Address - Street 1:1201 KNOX AVE
Practice Address - Street 2:
Practice Address - City:NORTH AUGUSTA
Practice Address - State:SC
Practice Address - Zip Code:29841-4056
Practice Address - Country:US
Practice Address - Phone:803-202-0182
Practice Address - Fax:803-202-0275
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-22
Last Update Date:2022-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC678156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician