1710400916 NPI number — MR. RANDY BROCKMAN CAADE 1711108

Table of content: MR. RANDY BROCKMAN CAADE 1711108 (NPI 1710400916)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710400916 NPI number — MR. RANDY BROCKMAN CAADE 1711108

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BROCKMAN
Provider First Name:
RANDY
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
CAADE 1711108
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:
1710400916
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/19/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
610 ELM ST STE 212
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN CARLOS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94070-3070
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
609 PRICE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
REDWOOD CITY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94063-1463
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
650-591-9623
Provider Business Practice Location Address Fax Number:
650-591-4163
Provider Enumeration Date:
07/19/2017

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: 101YA0400X , 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)





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