Basic Information
Provider Information
NPI: 1003139890
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: ENCISO
FirstName: RANDY
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 965 W SIERRA MADRE AVE
Address2: APT. #2
City: AZUSA
State: CA
PostalCode: 917021836
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: 2550 E FOOTHILL BLVD
Address2:  
City: PASADENA
State: CA
PostalCode: 911073406
CountryCode: US
TelephoneNumber: 6264631021
FaxNumber:  
Other Information
ProviderEnumerationDate: 03/08/2010
LastUpdateDate: 03/08/2010
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
225400000X  Y Respiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner 

No ID Information.


Home