Provider Demographics
NPI:1902988074
Name:JOHANSON, RANDEL EDWARD (RDO)
Entity Type:Individual
Prefix:
First Name:RANDEL
Middle Name:EDWARD
Last Name:JOHANSON
Suffix:
Gender:M
Credentials:RDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1722 MANGROVE AVE
Mailing Address - Street 2:SUITE 32
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95926-2300
Mailing Address - Country:US
Mailing Address - Phone:530-895-1474
Mailing Address - Fax:530-895-1441
Practice Address - Street 1:1722 MANGROVE AVE
Practice Address - Street 2:SUITE 32
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95926-2300
Practice Address - Country:US
Practice Address - Phone:530-895-1474
Practice Address - Fax:530-895-1441
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD3437156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician