Provider Demographics
NPI:1417544354
Name:RANDOLPH, ERIC
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:RANDOLPH
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 1:6433 E WASHINGTON ST STE 144
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-6627
Mailing Address - Country:US
Mailing Address - Phone:317-590-3363
Mailing Address - Fax:
Practice Address - Street 1:6433 E WASHINGTON ST STE 144
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46219-6627
Practice Address - Country:US
Practice Address - Phone:317-590-3363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-27
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN015125376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker