Provider Demographics
NPI:1184394413
Name:RANDOLPH, DAVE
Entity type:Individual
Prefix:
First Name:DAVE
Middle Name:
Last Name:RANDOLPH
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 1:2508 PLANTSIDE DR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40299-2538
Mailing Address - Country:US
Mailing Address - Phone:502-267-6030
Mailing Address - Fax:
Practice Address - Street 1:2508 PLANTSIDE DR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40299-2538
Practice Address - Country:US
Practice Address - Phone:502-267-6030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-17
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date: