MEDICARE: RANDY WHITESIDE PROSTHETICS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	224P00000X	Prosthetist

General Provider Information

NPI Number	:	1609386853
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RANDY WHITESIDE PROSTHETICS LLC

Provider Business Mailing Address
First Line	:	1190 E MISSOURI AVE STE 190
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85014-2736
Country	:	US
Telephone Number	:	602-596-1040
Fax Number	:	480-212-5944

Provider Business Practice Location Address
First Line	:	1190 E MISSOURI AVE STE 190
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85014-2736
Country	:	US
Telephone Number	:	602-596-1040
Fax Number	:	480-212-5944

Authorized Official
Title or Position	:	MANAGER
Name	:	MR. RANDALL WHITESIDE
Credential	:	CP
Telephone Number	:	602-596-4010

Provider Enumeration Date	:	10/02/2017
Last Update Date	:	10/02/2017

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