Provider Demographics
NPI:1710913678
Name:RANDOLPH, LOREN J (MS)
Entity Type:Individual
Prefix:
First Name:LOREN
Middle Name:J
Last Name:RANDOLPH
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 354
Mailing Address - Street 2:
Mailing Address - City:MAGNA
Mailing Address - State:UT
Mailing Address - Zip Code:84044-0354
Mailing Address - Country:US
Mailing Address - Phone:801-250-3541
Mailing Address - Fax:
Practice Address - Street 1:VAMC
Practice Address - Street 2:500 FOOTHILL BLVD (126)
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84148-0001
Practice Address - Country:US
Practice Address - Phone:801-584-1242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT111723-4101231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist