Healthcare Provider Details

I. General information

NPI: 1417499898
Provider Name (Legal Business Name): RANDY JAMES WUNSCHE JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/16/2016
Last Update Date: 11/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4587 ASHLEY LAKE CIR
VERO BEACH FL
32967-2601
US

IV. Provider business mailing address

4587 ASHLEY LAKE CIR
VERO BEACH FL
32967-2601
US

V. Phone/Fax

Practice location:
  • Phone: 772-633-3390
  • Fax:
Mailing address:
  • Phone: 772-633-3390
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number20548
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number9264
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: