Provider Demographics
NPI:1285001438
Name:RANDLE, KEITH
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:RANDLE
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 1:2100 HIGHAND DRIVE
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-4408
Mailing Address - Country:US
Mailing Address - Phone:949-689-8880
Mailing Address - Fax:
Practice Address - Street 1:2100 HIGHLAND DR
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-4408
Practice Address - Country:US
Practice Address - Phone:949-689-8880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-24
Last Update Date:2015-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACLR00348278291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory