Provider Demographics
NPI:1023268968
Name:RANDOLPH, SANDRA RENAE (AUD)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:RENAE
Last Name:RANDOLPH
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:RENAE
Other - Last Name:THOMPSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AUD
Mailing Address - Street 1:1900 WOODLAND DR
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-2045
Mailing Address - Country:US
Mailing Address - Phone:541-267-5151
Mailing Address - Fax:541-266-4595
Practice Address - Street 1:1900 WOODLAND DR
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-2045
Practice Address - Country:US
Practice Address - Phone:541-267-5151
Practice Address - Fax:541-266-4595
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-29
Last Update Date:2010-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR23138231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR930635514OtherNBMC GROUP TAX ID FOR BILLING
ORR0000WFBTVOtherNBMC GROUP MEDICARE
OR1407812365OtherNBMC MAIN GROUP NPI
OR161133OtherNBMC GROUP MEDICAID-DMAP
OR500600529Medicaid