Provider Demographics
NPI:1700423902
Name:BLAND, RANDY
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:
Last Name:BLAND
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:INTERMOUNTAIN CENTERS FOR HUMAN DEVELOPMENT INC.
Mailing Address - Street 2:PO BOX 86537
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85754-6537
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14047 W MONTE VISTA RD
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85395
Practice Address - Country:US
Practice Address - Phone:480-334-2092
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-06
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10126301385HR2055X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1700423902OtherTHERAPEUTIC FOSTER CARE
AZ10126301OtherAZ DEPT OF HEALTH SERVICES