Provider Demographics
NPI:1124870449
Name:NEELY, RANDY J
Entity type:Individual
Prefix:
First Name:RANDY
Middle Name:J
Last Name:NEELY
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 1:4473 COUNTY ROAD 140
Mailing Address - Street 2:
Mailing Address - City:QUITMAN
Mailing Address - State:MS
Mailing Address - Zip Code:39355-9611
Mailing Address - Country:US
Mailing Address - Phone:601-527-1238
Mailing Address - Fax:
Practice Address - Street 1:4473 COUNTY ROAD 140
Practice Address - Street 2:
Practice Address - City:QUITMAN
Practice Address - State:MS
Practice Address - Zip Code:39355-9611
Practice Address - Country:US
Practice Address - Phone:601-527-1238
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-02
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSRCP5261227800000X
MSRCP-5261227800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes227800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, Certified