Provider Demographics
NPI:1104633742
Name:MUNMON, RANDY LON JR
Entity type:Individual
Prefix:
First Name:RANDY
Middle Name:LON
Last Name:MUNMON
Suffix:JR
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 1:1900 POWELL ST STE 700
Mailing Address - Street 2:
Mailing Address - City:EMERYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94608-1889
Mailing Address - Country:US
Mailing Address - Phone:415-845-1160
Mailing Address - Fax:
Practice Address - Street 1:724 36TH ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-2328
Practice Address - Country:US
Practice Address - Phone:415-845-1160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-17
Last Update Date:2024-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 101YA0400X, 172A00000X, 374U00000X
CA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No172A00000XOther Service ProvidersDriver
No374U00000XNursing Service Related ProvidersHome Health Aide