Provider Demographics
NPI:1558744201
Name:PRUIT, RANDAL
Entity Type:Individual
Prefix:
First Name:RANDAL
Middle Name:
Last Name:PRUIT
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 1:2101 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101-3511
Mailing Address - Country:US
Mailing Address - Phone:575-693-6205
Mailing Address - Fax:
Practice Address - Street 1:2101 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101-3511
Practice Address - Country:US
Practice Address - Phone:575-693-6205
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-30
Last Update Date:2015-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator
No171R00000XOther Service ProvidersInterpreter
No171WV0202XOther Service ProvidersContractorVehicle Modifications