Provider Demographics
NPI:1790408029
Name:RANDOLPH, LAVONTAE LAROD
Entity Type:Individual
Prefix:
First Name:LAVONTAE
Middle Name:LAROD
Last Name:RANDOLPH
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 1:720 E CHARLESTON BLVD STE 60
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89104-1577
Mailing Address - Country:US
Mailing Address - Phone:702-377-8444
Mailing Address - Fax:
Practice Address - Street 1:720 E CHARLESTON BLVD STE 60
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89104-1577
Practice Address - Country:US
Practice Address - Phone:702-377-8444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-21
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant