1114961539 NPI number — RANDA BASCHARON,D.O. INC

Table of content: (NPI 1114961539)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114961539 NPI number — RANDA BASCHARON,D.O. INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RANDA BASCHARON,D.O. INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
ORTHOPEDIC & SPORTS MEDICINE INSTITUTE OF LAS VEGAS
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114961539
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/03/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4132 S RAINBOW BLVD
Provider Second Line Business Mailing Address:
#393
Provider Business Mailing Address City Name:
LAS VEGAS
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89103-3106
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-596-0036
Provider Business Mailing Address Fax Number:
702-947-7792

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7281 W SAHARA AVE
Provider Second Line Business Practice Location Address:
SUITE 110
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89117-2816
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-947-7790
Provider Business Practice Location Address Fax Number:
702-947-7792
Provider Enumeration Date:
06/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BASCHARON
Authorized Official First Name:
RANDA
Authorized Official Middle Name:
AMIN
Authorized Official Title or Position:
PRES, SEC,
Authorized Official Telephone Number:
702-596-0036

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  1103 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207X00000X , with the licence number: 2OA8358 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207XX0005X , with the licence number: 1103 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207XX0005X , with the licence number: 2OA8358 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100503044 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".
  • Identifier: XTE006922 . This is a "CALIF MEDI-CAL ID" identifier . This identifiers is of the category "OTHER".




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