Healthcare Provider Details

I. General information

NPI: 1023192234
Provider Name (Legal Business Name): RANDALL VINCENT RICKETTS D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 11/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26991 CROWN VALLEY PKWY
MISSION VIEJO CA
92691-6528
US

IV. Provider business mailing address

26991 CROWN VALLEY PKWY # 100
MISSION VIEJO CA
92691-6528
US

V. Phone/Fax

Practice location:
  • Phone: 949-582-5430
  • Fax: 949-348-9513
Mailing address:
  • Phone: 949-923-3277
  • Fax: 855-812-5865

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A4956
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: