Provider Demographics
NPI:1205867124
Name:WIRTZ, RANDY R
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:R
Last Name:WIRTZ
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 1:2045 ROYAL AVE.
Mailing Address - Street 2:STE.#102
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93065
Mailing Address - Country:US
Mailing Address - Phone:805-584-2404
Mailing Address - Fax:
Practice Address - Street 1:2045 ROYAL AVE.
Practice Address - Street 2:STE.#102
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065
Practice Address - Country:US
Practice Address - Phone:805-584-2404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC26326111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0263260Medicare ID - Type Unspecified