Provider Demographics
NPI:1720774136
Name:SMITH, RANDY
Entity Type:Individual
Prefix:MR
First Name:RANDY
Middle Name:
Last Name:SMITH
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 1:4039 COUNTY ROAD 31
Mailing Address - Street 2:
Mailing Address - City:UNION SPRINGS
Mailing Address - State:AL
Mailing Address - Zip Code:36089-3831
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4039 COUNTY ROAD 31
Practice Address - Street 2:
Practice Address - City:UNION SPRINGS
Practice Address - State:AL
Practice Address - Zip Code:36089-3831
Practice Address - Country:US
Practice Address - Phone:334-473-7710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-18
Last Update Date:2023-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker