Provider Demographics
NPI:1669049250
Name:RICHARD, RANDY JAY JR
Entity type:Individual
Prefix:
First Name:RANDY
Middle Name:JAY
Last Name:RICHARD
Suffix:JR
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6400 TUPELO DR
Mailing Address - Street 2:
Mailing Address - City:CITRUS HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:95621-1741
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:600 STARLING LN
Practice Address - Street 2:
Practice Address - City:PILOT HILL
Practice Address - State:CA
Practice Address - Zip Code:95664-9201
Practice Address - Country:US
Practice Address - Phone:530-906-1512
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-10
Last Update Date:2025-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician