Provider Demographics
NPI:1497821920
Name:FLORES, RANDY DANIEL
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:DANIEL
Last Name:FLORES
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 1:188 W IVEY RD
Mailing Address - Street 2:
Mailing Address - City:HUACHUCA CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:85616-8227
Mailing Address - Country:US
Mailing Address - Phone:520-456-1416
Mailing Address - Fax:
Practice Address - Street 1:188 W IVEY RD
Practice Address - Street 2:
Practice Address - City:HUACHUCA CITY
Practice Address - State:AZ
Practice Address - Zip Code:85616-8227
Practice Address - Country:US
Practice Address - Phone:520-456-1416
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-27
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ385HR2055X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ114178Medicaid