Provider Demographics
NPI:1639209877
Name:TACKETT, RANDY HAROLD
Entity Type:Individual
Prefix:MR
First Name:RANDY
Middle Name:HAROLD
Last Name:TACKETT
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 1:1821 N 150 W
Mailing Address - Street 2:
Mailing Address - City:WABASH
Mailing Address - State:IN
Mailing Address - Zip Code:46992-8728
Mailing Address - Country:US
Mailing Address - Phone:260-563-0142
Mailing Address - Fax:260-563-6565
Practice Address - Street 1:1821 N 150 W
Practice Address - Street 2:
Practice Address - City:WABASH
Practice Address - State:IN
Practice Address - Zip Code:46992-8728
Practice Address - Country:US
Practice Address - Phone:260-563-0142
Practice Address - Fax:260-563-6565
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WH0202XOther Service ProvidersContractorHome Modifications