Healthcare Provider Details

I. General information

NPI: 1821770140
Provider Name (Legal Business Name): RANDY CANCINO ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2023
Last Update Date: 08/04/2023
Certification Date: 08/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 UNIVERSITY AVE
RIVERSIDE CA
92521-0001
US

IV. Provider business mailing address

111 W HARRISON ST UNIT 334
CORONA CA
92878-3407
US

V. Phone/Fax

Practice location:
  • Phone: 951-827-1012
  • Fax:
Mailing address:
  • Phone: 714-788-3867
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2000054404
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: