Provider Demographics
NPI:1194802306
Name:RANDA AND WAHL, A PHYSICAL THERAPY CORP.
Entity type:Organization
Organization Name:RANDA AND WAHL, A PHYSICAL THERAPY CORP.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:RANDA
Authorized Official - Suffix:
Authorized Official - Credentials:PT, OCS
Authorized Official - Phone:760-256-2800
Mailing Address - Street 1:1815 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BARSTOW
Mailing Address - State:CA
Mailing Address - Zip Code:92311-3234
Mailing Address - Country:US
Mailing Address - Phone:760-256-2800
Mailing Address - Fax:760-256-2809
Practice Address - Street 1:1815 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BARSTOW
Practice Address - State:CA
Practice Address - Zip Code:92311-3234
Practice Address - Country:US
Practice Address - Phone:760-256-2800
Practice Address - Fax:760-256-2809
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 28176261QP2000X
CAPT 25062261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ07464ZOtherBLUE SHIELD GROUP ID
CAZZZ27393ZMedicare ID - Type UnspecifiedMEDICARE GROUP ID