Provider Demographics
NPI:1417009614
Name:CLENDENIN, RANDALL W (CO, C-PED)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:W
Last Name:CLENDENIN
Suffix:
Gender:M
Credentials:CO, C-PED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2301 N CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27405-4309
Mailing Address - Country:US
Mailing Address - Phone:336-333-9081
Mailing Address - Fax:336-333-9083
Practice Address - Street 1:2301 N CHURCH ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27405-4309
Practice Address - Country:US
Practice Address - Phone:336-333-9081
Practice Address - Fax:336-333-9083
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7795035Medicaid