Provider Demographics
NPI:1750753307
Name:CARLSON, RANDY (LSE)
Entity type:Individual
Prefix:
First Name:RANDY
Middle Name:
Last Name:CARLSON
Suffix:
Gender:M
Credentials:LSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 RAILWAY ST N DEPT 266
Mailing Address - Street 2:
Mailing Address - City:FESSENDEN
Mailing Address - State:ND
Mailing Address - Zip Code:58438-7427
Mailing Address - Country:US
Mailing Address - Phone:701-547-3694
Mailing Address - Fax:701-547-3348
Practice Address - Street 1:600 RAILWAY ST N DEPT 266
Practice Address - Street 2:
Practice Address - City:FESSENDEN
Practice Address - State:ND
Practice Address - Zip Code:58438-7427
Practice Address - Country:US
Practice Address - Phone:701-547-3694
Practice Address - Fax:701-547-3348
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-22
Last Update Date:2015-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator