Provider Demographics
NPI:1184089203
Name:RANDALL, BENJAMIN (ATC)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:RANDALL
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5747 MEMORIAL GYM UNIVERSITY OF MAINE
Mailing Address - Street 2:
Mailing Address - City:ORONO
Mailing Address - State:ME
Mailing Address - Zip Code:04469-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5747 MEMORIAL GYM UNIVERSITY OF MAINE
Practice Address - Street 2:
Practice Address - City:ORONO
Practice Address - State:ME
Practice Address - Zip Code:04469-0001
Practice Address - Country:US
Practice Address - Phone:207-581-1088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-16
Last Update Date:2015-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEAT509246Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other