Provider Demographics
NPI:1417126624
Name:SHINE, RANDY
Entity Type:Individual
Prefix:MR
First Name:RANDY
Middle Name:
Last Name:SHINE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:254 FRANKLIN STREET
Mailing Address - Street 2:LAKE SHORE BEHAVIORAL HEALTH
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14202
Mailing Address - Country:US
Mailing Address - Phone:716-842-0440
Mailing Address - Fax:716-842-4069
Practice Address - Street 1:430 NIAGARA STREET
Practice Address - Street 2:BLENDED CASE MANAGEMENT
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14201
Practice Address - Country:US
Practice Address - Phone:716-856-2587
Practice Address - Fax:716-856-2608
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-22
Last Update Date:2008-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator