Provider Demographics
NPI:1841580669
Name:MCLAIN, RANDALL UYLESSES (IDC)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:UYLESSES
Last Name:MCLAIN
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC 466
Mailing Address - Street 2:BOX 3
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:96595
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:PSC 466
Practice Address - Street 2:BOX 3
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96595
Practice Address - Country:US
Practice Address - Phone:970-640-6016
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-13
Last Update Date:2011-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman