Provider Demographics
NPI:1154048569
Name:DANIEL, RANDY OLUSHOLA
Entity type:Individual
Prefix:
First Name:RANDY
Middle Name:OLUSHOLA
Last Name:DANIEL
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 1:2612 HIDDEN HILL DR
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76543-5751
Mailing Address - Country:US
Mailing Address - Phone:214-440-8918
Mailing Address - Fax:
Practice Address - Street 1:2612 HIDDEN HILL DR
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76543-5751
Practice Address - Country:US
Practice Address - Phone:214-440-8918
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-26
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX22394216343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)