Provider Demographics
NPI:1386751816
Name:HONDO, RANDY ALLEN HERRERA (PT)
Entity type:Individual
Prefix:
First Name:RANDY ALLEN
Middle Name:HERRERA
Last Name:HONDO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:149 W DESFORD ST
Mailing Address - Street 2:
Mailing Address - City:CARSON
Mailing Address - State:CA
Mailing Address - Zip Code:90745-1412
Mailing Address - Country:US
Mailing Address - Phone:714-424-0290
Mailing Address - Fax:714-424-0278
Practice Address - Street 1:11100 WARNER AVE
Practice Address - Street 2:SUITE 218
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-7506
Practice Address - Country:US
Practice Address - Phone:714-424-0290
Practice Address - Fax:714-424-0278
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT24918225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT24918OtherPHYSICAL THERAPY LICENSE