Provider Demographics
NPI:1538431143
Name:WARNDAHL, RANDY CARL
Entity type:Individual
Prefix:MR
First Name:RANDY
Middle Name:CARL
Last Name:WARNDAHL
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 1:1105 OAKRIDGE MANOR DR
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-7654
Mailing Address - Country:US
Mailing Address - Phone:813-418-0075
Mailing Address - Fax:
Practice Address - Street 1:1105 OAKRIDGE MANOR DR
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-7654
Practice Address - Country:US
Practice Address - Phone:813-418-0075
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-30
Last Update Date:2012-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLW653-723-65-097-0172A00000X, 343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No172A00000XOther Service ProvidersDriver