Provider Demographics
NPI:1790579274
Name:HOLYFIELD, RANDALL LEE JR (HAD)
Entity type:Individual
Prefix:MR
First Name:RANDALL
Middle Name:LEE
Last Name:HOLYFIELD
Suffix:JR
Gender:
Credentials:HAD
Other - Prefix:
Other - First Name:RANDY
Other - Middle Name:LEE
Other - Last Name:HOLYFIELD
Other - Suffix:JR
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2601 S LEMAY AVE UNIT 41
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-2297
Mailing Address - Country:US
Mailing Address - Phone:970-286-2607
Mailing Address - Fax:
Practice Address - Street 1:2601 S LEMAY AVE UNIT 41
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-2297
Practice Address - Country:US
Practice Address - Phone:970-286-2607
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-08
Last Update Date:2025-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COHAD.0000575237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist