Provider Demographics
NPI:1558780924
Name:RANDALL, LORENZO
Entity Type:Individual
Prefix:
First Name:LORENZO
Middle Name:
Last Name:RANDALL
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:PO BOX 1577
Mailing Address - Street 2:
Mailing Address - City:WALLER
Mailing Address - State:TX
Mailing Address - Zip Code:77484-1577
Mailing Address - Country:US
Mailing Address - Phone:888-344-2947
Mailing Address - Fax:281-622-4381
Practice Address - Street 1:33518 HALEY RD STE 1
Practice Address - Street 2:
Practice Address - City:WALLER
Practice Address - State:TX
Practice Address - Zip Code:77484-5110
Practice Address - Country:US
Practice Address - Phone:888-344-2947
Practice Address - Fax:281-622-4381
Is Sole Proprietor?:No
Enumeration Date:2014-04-14
Last Update Date:2014-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXCNIM 2902246ZE0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZE0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherElectroneurodiagnostic
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX337550Medicare PIN