Provider Demographics
NPI:1376688796
Name:RANDALL, JEFFREY DWAYNE (MPC)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:DWAYNE
Last Name:RANDALL
Suffix:
Gender:M
Credentials:MPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 HIGHWAY 90 E
Mailing Address - Street 2:
Mailing Address - City:LITTLE RIVER
Mailing Address - State:SC
Mailing Address - Zip Code:29566
Mailing Address - Country:US
Mailing Address - Phone:803-422-7231
Mailing Address - Fax:
Practice Address - Street 1:501 HIGHWAY 90 E
Practice Address - Street 2:
Practice Address - City:LITTLE RIVER
Practice Address - State:SC
Practice Address - Zip Code:29566-9261
Practice Address - Country:US
Practice Address - Phone:803-422-7231
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC421504Medicaid
SC421504Medicaid