Provider Demographics
NPI:1558132308
Name:RANDELL, CHRISTOPHER J
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:J
Last Name:RANDELL
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 1:355 AVENUE A
Mailing Address - Street 2:
Mailing Address - City:OPELOUSAS
Mailing Address - State:LA
Mailing Address - Zip Code:70570-1248
Mailing Address - Country:US
Mailing Address - Phone:337-692-9501
Mailing Address - Fax:
Practice Address - Street 1:355 AVENUE A
Practice Address - Street 2:
Practice Address - City:OPELOUSAS
Practice Address - State:LA
Practice Address - Zip Code:70570-1248
Practice Address - Country:US
Practice Address - Phone:337-692-9501
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-10
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA007388422172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver