Healthcare Provider Details

I. General information

NPI: 1174564009
Provider Name (Legal Business Name): RANDA BASCHARON D.O., INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2006
Last Update Date: 02/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6850 N DURANGO DR #218
LAS VEGAS NV
89149-4595
US

IV. Provider business mailing address

4132 S RAINBOW BLVD #393
LAS VEGAS NV
89103-3106
US

V. Phone/Fax

Practice location:
  • Phone: 702-947-7790
  • Fax: 702-947-7792
Mailing address:
  • Phone: 702-596-0036
  • Fax: 702-947-7792

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number20A8358
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number1103
License Number StateNV
# 3
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number20A8358
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number1103
License Number StateNV

VIII. Authorized Official

Name: RANDA AMIN BASCHARON
Title or Position: OWNER PRES SEC ETC
Credential: DO
Phone: 702-596-0036