Provider Demographics
NPI:1467805184
Name:RANDALL, QUILNINIOUS
Entity Type:Individual
Prefix:
First Name:QUILNINIOUS
Middle Name:
Last Name:RANDALL
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 1:3313 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02130-2691
Mailing Address - Country:US
Mailing Address - Phone:508-789-2365
Mailing Address - Fax:
Practice Address - Street 1:3313 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02130-2691
Practice Address - Country:US
Practice Address - Phone:508-789-2365
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-18
Last Update Date:2016-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA$$$$$$$$$OtherQUILNINIOUS