Healthcare Provider Details

I. General information

NPI: 1639396237
Provider Name (Legal Business Name): RANDALL HEPWORTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2007
Last Update Date: 07/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 RIVER ROCK DR # 114
FOLSOM CA
95630-0367
US

IV. Provider business mailing address

1000 RIVER ROCK DR # 114
FOLSOM CA
95630-2093
US

V. Phone/Fax

Practice location:
  • Phone: 916-989-2086
  • Fax: 916-989-0367
Mailing address:
  • Phone: 916-989-2086
  • Fax: 916-989-0367

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG45570
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License NumberG45570
License Number StateCA

VIII. Authorized Official

Name: DR. RANDALL CLAUD HEPWORTH
Title or Position: PHYSICIAN
Credential: MD
Phone: 916-404-2715