Provider Demographics
NPI:1982830691
Name:SCHROEDER, RANDALL DAVID
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:DAVID
Last Name:SCHROEDER
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 1:3095 S PEAKS VIEW DRIVE
Mailing Address - Street 2:POB 50901
Mailing Address - City:PARKS
Mailing Address - State:AZ
Mailing Address - Zip Code:86018
Mailing Address - Country:US
Mailing Address - Phone:928-607-9562
Mailing Address - Fax:
Practice Address - Street 1:3095 S PEAKS VIEW DR
Practice Address - Street 2:POB 50901
Practice Address - City:PARKS
Practice Address - State:AZ
Practice Address - Zip Code:86018-0901
Practice Address - Country:US
Practice Address - Phone:928-607-9562
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-09
Last Update Date:2009-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1446377385HR2055X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child