Healthcare Provider Details

I. General information

NPI: 1609386853
Provider Name (Legal Business Name): RANDY WHITESIDE PROSTHETICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2017
Last Update Date: 10/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1190 E MISSOURI AVE STE 190
PHOENIX AZ
85014-2736
US

IV. Provider business mailing address

1190 E MISSOURI AVE STE 190
PHOENIX AZ
85014-2736
US

V. Phone/Fax

Practice location:
  • Phone: 602-596-1040
  • Fax: 480-212-5944
Mailing address:
  • Phone: 602-596-1040
  • Fax: 480-212-5944

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number
License Number State

VIII. Authorized Official

Name: MR. RANDALL WHITESIDE
Title or Position: MANAGER
Credential: CP
Phone: 602-596-4010