Basic Information
Provider Information | |||||||||
NPI: | 1023268968 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RANDOLPH | ||||||||
FirstName: | SANDRA | ||||||||
MiddleName: | RENAE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | AUD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | THOMPSON | ||||||||
OtherFirstName: | SANDRA | ||||||||
OtherMiddleName: | RENAE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | AUD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1900 WOODLAND DR | ||||||||
Address2: |   | ||||||||
City: | COOS BAY | ||||||||
State: | OR | ||||||||
PostalCode: | 974202045 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5412675151 | ||||||||
FaxNumber: | 5412664595 | ||||||||
Practice Location | |||||||||
Address1: | 1900 WOODLAND DR | ||||||||
Address2: |   | ||||||||
City: | COOS BAY | ||||||||
State: | OR | ||||||||
PostalCode: | 974202045 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5412675151 | ||||||||
FaxNumber: | 5412664595 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/29/2008 | ||||||||
LastUpdateDate: | 12/21/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | 23138 | OR | Y |   | Speech, Language and Hearing Service Providers | Audiologist |   |
ID Information
ID | Type | State | Issuer | Description | 930635514 | 01 | OR | NBMC GROUP TAX ID FOR BILLING | OTHER | R0000WFBTV | 01 | OR | NBMC GROUP MEDICARE | OTHER | 1407812365 | 01 | OR | NBMC MAIN GROUP NPI | OTHER | 161133 | 01 | OR | NBMC GROUP MEDICAID-DMAP | OTHER | 500600529 | 05 | OR |   | MEDICAID |