Provider Demographics
NPI:1831112697
Name:ROSE, RANDY WAYNE
Entity Type:Individual
Prefix:MR
First Name:RANDY
Middle Name:WAYNE
Last Name:ROSE
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 1:1505 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HILTON HEAD
Mailing Address - State:SC
Mailing Address - Zip Code:29926-1608
Mailing Address - Country:US
Mailing Address - Phone:843-547-5832
Mailing Address - Fax:
Practice Address - Street 1:1505 MAIN ST
Practice Address - Street 2:
Practice Address - City:HILTON HEAD
Practice Address - State:SC
Practice Address - Zip Code:29926
Practice Address - Country:US
Practice Address - Phone:843-547-5832
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2018-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC0640237700000X
CAHA2772237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist