Provider Demographics
NPI:1386966976
Name:RANDA BASCHARON, DO, INC
Entity type:Organization
Organization Name:RANDA BASCHARON, DO, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:BASCHARON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:702-947-7790
Mailing Address - Street 1:2980 N BEVERLY GLEN CIR
Mailing Address - Street 2:STE 301
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90077-1726
Mailing Address - Country:US
Mailing Address - Phone:310-474-9809
Mailing Address - Fax:
Practice Address - Street 1:7281 W SAHARA AVE
Practice Address - Street 2:STE 110
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89117-2816
Practice Address - Country:US
Practice Address - Phone:702-947-7790
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RANDA BASCHARON, DO, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-02-23
Last Update Date:2011-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV1103332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site
Provider Identifiers
StateIdentifier IDID TypeIssuer
H87776Medicare UPIN