Healthcare Provider Details

I. General information

NPI: 1316338718
Provider Name (Legal Business Name): RANDOLPH DALE BLATTLER R.N., RNFA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2015
Last Update Date: 02/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8624 CARLTON OAKS DR
SANTEE CA
92071-2214
US

IV. Provider business mailing address

4647 ZION AVE
SAN DIEGO CA
92120-2507
US

V. Phone/Fax

Practice location:
  • Phone: 619-851-7625
  • Fax:
Mailing address:
  • Phone: 619-528-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License Number547610
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: