Provider Demographics
NPI:1689712010
Name:CANTRELL, RANDALL KENNETH (GENERAL CONTRACTOR)
Entity Type:Individual
Prefix:MR
First Name:RANDALL
Middle Name:KENNETH
Last Name:CANTRELL
Suffix:
Gender:M
Credentials:GENERAL CONTRACTOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8902 ORBY CANTRELL HWY
Mailing Address - Street 2:
Mailing Address - City:POUND
Mailing Address - State:VA
Mailing Address - Zip Code:24279-3216
Mailing Address - Country:US
Mailing Address - Phone:276-796-5789
Mailing Address - Fax:276-796-5789
Practice Address - Street 1:8902 ORBY CANTRELL HWY
Practice Address - Street 2:
Practice Address - City:POUND
Practice Address - State:VA
Practice Address - Zip Code:24279-3216
Practice Address - Country:US
Practice Address - Phone:276-796-5789
Practice Address - Fax:276-796-5789
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2705030223171WH0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WH0202XOther Service ProvidersContractorHome Modifications
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010277388Medicaid