Provider Demographics
NPI:1639238777
Name:DECOS, RANDOLPH STEVEN (LMT)
Entity Type:Individual
Prefix:MR
First Name:RANDOLPH
Middle Name:STEVEN
Last Name:DECOS
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4084 LINWOOD ST
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34232-3806
Mailing Address - Country:US
Mailing Address - Phone:941-378-9072
Mailing Address - Fax:
Practice Address - Street 1:2106 BISPHAM ROAD
Practice Address - Street 2:SUITE A
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34231
Practice Address - Country:US
Practice Address - Phone:941-925-3557
Practice Address - Fax:941-925-3557
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA0019618225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
C7850Medicare UPIN