Provider Demographics
NPI:1265167282
Name:BERRY, RANDALL LEE
Entity type:Individual
Prefix:
First Name:RANDALL
Middle Name:LEE
Last Name:BERRY
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 1:1 AVENUE C BULDING
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WV
Mailing Address - Zip Code:25053
Mailing Address - Country:US
Mailing Address - Phone:304-369-6400
Mailing Address - Fax:
Practice Address - Street 1:1 AVENUE C BULDING
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WV
Practice Address - Zip Code:25053
Practice Address - Country:US
Practice Address - Phone:304-369-6400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-22
Last Update Date:2022-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant