Provider Demographics
NPI:1407322159
Name:RANDLE, INETA MOORE
Entity type:Individual
Prefix:
First Name:INETA
Middle Name:MOORE
Last Name:RANDLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 CROWELL ST
Mailing Address - Street 2:
Mailing Address - City:WEST POINT
Mailing Address - State:MS
Mailing Address - Zip Code:39773-7568
Mailing Address - Country:US
Mailing Address - Phone:662-295-1299
Mailing Address - Fax:662-492-1961
Practice Address - Street 1:124 CROWELL ST
Practice Address - Street 2:
Practice Address - City:WEST POINT
Practice Address - State:MS
Practice Address - Zip Code:39773-7568
Practice Address - Country:US
Practice Address - Phone:662-295-1299
Practice Address - Fax:662-492-1961
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-21
Last Update Date:2018-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)Group - Single Specialty
No172A00000XOther Service ProvidersDriverGroup - Single Specialty