Provider Demographics
NPI:1386243566
Name:FOWLER, RANDALL WILLIAM JR
Entity type:Individual
Prefix:
First Name:RANDALL
Middle Name:WILLIAM
Last Name:FOWLER
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5321 WENATCHEE WAY
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92509-7819
Mailing Address - Country:US
Mailing Address - Phone:626-373-5591
Mailing Address - Fax:
Practice Address - Street 1:423 MACKAY DR
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-3230
Practice Address - Country:US
Practice Address - Phone:909-383-1073
Practice Address - Fax:909-388-1456
Is Sole Proprietor?:No
Enumeration Date:2020-10-20
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator