Provider Demographics
NPI:1245500453
Name:MILES, RANDI
Entity type:Individual
Prefix:
First Name:RANDI
Middle Name:
Last Name:MILES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3407 AIRPORT WAY
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99709-4761
Mailing Address - Country:US
Mailing Address - Phone:907-456-4524
Mailing Address - Fax:
Practice Address - Street 1:3407 AIRPORT WAY
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99709-4761
Practice Address - Country:US
Practice Address - Phone:907-456-4524
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-04
Last Update Date:2013-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMH0157Medicaid
K0000WCHCPMedicare PIN