=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386966976
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RANDA BASCHARON, DO, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/23/2010
-----------------------------------------------------
Last Update Date | 03/01/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7281 W SAHARA AVE STE 110
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89117-2816
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-947-7790
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2980 N BEVERLY GLEN CIR STE 301
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90077-1726
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-474-9809
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | RANDA BASCHARON
-----------------------------------------------------
Credential | D.O.
-----------------------------------------------------
Telephone | 702-947-7790
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332900000X
-----------------------------------------------------
Taxonomy Name | Non-Pharmacy Dispensing Site
-----------------------------------------------------
License Number | 1103
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------