Provider Demographics
NPI:1992516850
Name:MALCOM, RANDALL JOE
Entity type:Individual
Prefix:
First Name:RANDALL
Middle Name:JOE
Last Name:MALCOM
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 1:125 HAYMAKER HVN
Mailing Address - Street 2:
Mailing Address - City:COZAD
Mailing Address - State:NE
Mailing Address - Zip Code:69130-1347
Mailing Address - Country:US
Mailing Address - Phone:308-325-6992
Mailing Address - Fax:
Practice Address - Street 1:125 HAYMAKER HVN
Practice Address - Street 2:
Practice Address - City:COZAD
Practice Address - State:NE
Practice Address - Zip Code:69130-1347
Practice Address - Country:US
Practice Address - Phone:308-325-6992
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-18
Last Update Date:2025-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant