Healthcare Provider Details

I. General information

NPI: 1780268631
Provider Name (Legal Business Name): RANDALL FOOT AND ANKLE SURGERY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2021
Last Update Date: 11/22/2021
Certification Date: 11/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 PACIFIC AVE STE D
LONG BEACH CA
90806-1468
US

IV. Provider business mailing address

6444 SAN FERNANDO RD UNIT 5611
GLENDALE CA
91201-2124
US

V. Phone/Fax

Practice location:
  • Phone: 562-337-8401
  • Fax:
Mailing address:
  • Phone: 323-672-6549
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State

VIII. Authorized Official

Name: MARTINA RANDALL
Title or Position: CEO
Credential:
Phone: 267-934-6996