=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710001961
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUN CITY FOOT CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/16/2007
-----------------------------------------------------
Last Update Date | 12/05/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3320 NORTH BUFFALO DRIVE STE 107
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89129-7410
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-256-8454
-----------------------------------------------------
Fax | 702-256-0387
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3320 NORTH BUFFALO DRIVE STE 107
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89129-7410
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-256-8454
-----------------------------------------------------
Fax | 702-256-0387
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. RANDY LEE GUBLER
-----------------------------------------------------
Credential | D.P.M.
-----------------------------------------------------
Telephone | 702-256-8454
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | 9804
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------