Provider Demographics
NPI:1770391450
Name:NELSON, RANDALL KENNETH (CPO)
Entity type:Individual
Prefix:
First Name:RANDALL
Middle Name:KENNETH
Last Name:NELSON
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 PINEWELL DR
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23503-1763
Mailing Address - Country:US
Mailing Address - Phone:763-567-0125
Mailing Address - Fax:
Practice Address - Street 1:309 PINEWELL DR
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23503-1763
Practice Address - Country:US
Practice Address - Phone:763-567-0125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-26
Last Update Date:2024-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist