Provider Demographics
NPI:1609378991
Name:RANDOLPH DIABETES AND WELLNESS LLC
Entity Type:Organization
Organization Name:RANDOLPH DIABETES AND WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:T
Authorized Official - Last Name:RANDOLPH
Authorized Official - Suffix:
Authorized Official - Credentials:APRN-C
Authorized Official - Phone:813-846-7698
Mailing Address - Street 1:13047 W LINEBAUGH AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33626-4487
Mailing Address - Country:US
Mailing Address - Phone:813-475-6542
Mailing Address - Fax:813-475-6874
Practice Address - Street 1:13047 W LINEBAUGH AVE STE 102
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33626-4487
Practice Address - Country:US
Practice Address - Phone:813-475-6542
Practice Address - Fax:813-475-6874
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-02
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207QA0505X, 261QH0100X
FLARNP9318390363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Multi-Specialty
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth ServiceGroup - Single Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty