Provider Demographics
NPI:1588079537
Name:RANDALL, KALVIN (STNA)
Entity type:Individual
Prefix:
First Name:KALVIN
Middle Name:
Last Name:RANDALL
Suffix:
Gender:M
Credentials:STNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:980 ISLINGTON ST
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43610-1245
Mailing Address - Country:US
Mailing Address - Phone:419-699-3552
Mailing Address - Fax:
Practice Address - Street 1:980 ISLINGTON ST
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43610-1245
Practice Address - Country:US
Practice Address - Phone:419-699-3552
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-29
Last Update Date:2014-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2940741Medicaid