Provider Demographics
NPI:1982892501
Name:RANDALL B RIGDON LLC
Entity type:Organization
Organization Name:RANDALL B RIGDON LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:B
Authorized Official - Last Name:RIGDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-536-3634
Mailing Address - Street 1:270 N SYKES CREEK PKWY
Mailing Address - Street 2:SUITE 202
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32953-3492
Mailing Address - Country:US
Mailing Address - Phone:321-454-2468
Mailing Address - Fax:321-454-2469
Practice Address - Street 1:270 N SYKES CREEK PKWY
Practice Address - Street 2:SUITE 202
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32953-3492
Practice Address - Country:US
Practice Address - Phone:321-454-2468
Practice Address - Fax:321-454-2469
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-09
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME75248261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG66873Medicare UPIN