Provider Demographics
NPI:1104215995
Name:SIBOLE, RANDY
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:
Last Name:SIBOLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3228 W AVENUE J3
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93536-6184
Mailing Address - Country:US
Mailing Address - Phone:661-942-5191
Mailing Address - Fax:
Practice Address - Street 1:3228 W AVENUE J3
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93536-6184
Practice Address - Country:US
Practice Address - Phone:661-942-5191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-15
Last Update Date:2015-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT1130225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant