Provider Demographics
NPI:1588833412
Name:STEVE RANDLE
Entity Type:Organization
Organization Name:STEVE RANDLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:
Authorized Official - Last Name:RANDLE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:662-256-8481
Mailing Address - Street 1:PO BOX 475
Mailing Address - Street 2:
Mailing Address - City:AMORY
Mailing Address - State:MS
Mailing Address - Zip Code:38821-0475
Mailing Address - Country:US
Mailing Address - Phone:662-256-8481
Mailing Address - Fax:
Practice Address - Street 1:307 MAIN ST S
Practice Address - Street 2:
Practice Address - City:AMORY
Practice Address - State:MS
Practice Address - Zip Code:38821-4219
Practice Address - Country:US
Practice Address - Phone:662-256-8481
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-25
Last Update Date:2011-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS515332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0129050001Medicare NSC