Provider Demographics
NPI:1578741617
Name:DR. RANDY L. HERTNEKY
Entity Type:Organization
Organization Name:DR. RANDY L. HERTNEKY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:L
Authorized Official - Last Name:HERTNEKY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:970-848-5345
Mailing Address - Street 1:105 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:CO
Mailing Address - Zip Code:80759-1913
Mailing Address - Country:US
Mailing Address - Phone:970-848-5345
Mailing Address - Fax:970-848-5346
Practice Address - Street 1:105 S MAIN ST
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:CO
Practice Address - Zip Code:80759-1913
Practice Address - Country:US
Practice Address - Phone:970-848-5345
Practice Address - Fax:970-848-5346
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DR. RANDY L. HERTNEKY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-01-31
Last Update Date:2008-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO08010928Medicaid
CO08010928Medicaid
COC77483Medicare PIN
CO0233130001Medicare NSC