Provider Demographics
NPI:1497041065
Name:JOHNSON, RANDY LEE
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:LEE
Last Name:JOHNSON
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 1:824 9TH ST N
Mailing Address - Street 2:P.O.BOX 186
Mailing Address - City:SARTELL
Mailing Address - State:MN
Mailing Address - Zip Code:56377-2248
Mailing Address - Country:US
Mailing Address - Phone:320-290-9506
Mailing Address - Fax:866-392-7760
Practice Address - Street 1:824 9TH ST N
Practice Address - Street 2:
Practice Address - City:SARTELL
Practice Address - State:MN
Practice Address - Zip Code:56377-2248
Practice Address - Country:US
Practice Address - Phone:320-290-9506
Practice Address - Fax:866-392-7760
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-22
Last Update Date:2011-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WH0202XOther Service ProvidersContractorHome Modifications