Provider Demographics
NPI:1508194481
Name:RANDOLPH, TICE JAMES
Entity Type:Individual
Prefix:
First Name:TICE
Middle Name:JAMES
Last Name:RANDOLPH
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 1:123 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:NC
Mailing Address - Zip Code:28752-4548
Mailing Address - Country:US
Mailing Address - Phone:828-659-8879
Mailing Address - Fax:828-659-6888
Practice Address - Street 1:123 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:NC
Practice Address - Zip Code:28752-4548
Practice Address - Country:US
Practice Address - Phone:828-659-8879
Practice Address - Fax:828-659-6888
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-03
Last Update Date:2009-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHC2338251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3408122Medicaid
NC6600926Medicaid