Healthcare Provider Details

I. General information

NPI: 1083746705
Provider Name (Legal Business Name): ANNE WILLY RANDALL BS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6160 MISSION GORGE RD SUITE 400
SAN DIEGO CA
92120-3410
US

IV. Provider business mailing address

5625 AZTEC DR
LA MESA CA
91942-1947
US

V. Phone/Fax

Practice location:
  • Phone: 619-528-4000
  • Fax:
Mailing address:
  • Phone: 619-460-2562
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number10222
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: