1386751816 NPI number — RANDY ALLEN HERRERA HONDO PT

Table of content: RANDY ALLEN HERRERA HONDO PT (NPI 1386751816)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386751816 NPI number — RANDY ALLEN HERRERA HONDO PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HONDO
Provider First Name:
RANDY ALLEN
Provider Middle Name:
HERRERA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1386751816
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/13/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
149 W DESFORD ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CARSON
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90745-1412
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-424-0290
Provider Business Mailing Address Fax Number:
714-424-0278

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11100 WARNER AVE
Provider Second Line Business Practice Location Address:
SUITE 218
Provider Business Practice Location Address City Name:
FOUNTAIN VALLEY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92708-7506
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-424-0290
Provider Business Practice Location Address Fax Number:
714-424-0278
Provider Enumeration Date:
08/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT24918 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: PT24918 . This is a "PHYSICAL THERAPY LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com