Provider Demographics
NPI:1891195905
Name:SMITH, RANDOLPH
Entity Type:Individual
Prefix:
First Name:RANDOLPH
Middle Name:
Last Name:SMITH
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 1:1487 MUNROE FALLS AVE
Mailing Address - Street 2:
Mailing Address - City:CUYAHOGA FALLS
Mailing Address - State:OH
Mailing Address - Zip Code:44221-3674
Mailing Address - Country:US
Mailing Address - Phone:330-329-6598
Mailing Address - Fax:
Practice Address - Street 1:7651 CHARLTON CIR
Practice Address - Street 2:
Practice Address - City:NORTHFIELD
Practice Address - State:OH
Practice Address - Zip Code:44067-2472
Practice Address - Country:US
Practice Address - Phone:440-759-1890
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-26
Last Update Date:2014-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker