Provider Demographics
NPI:1215562236
Name:WALK RUN RANDALL
Entity Type:Organization
Organization Name:WALK RUN RANDALL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARTINA
Authorized Official - Middle Name:RENE
Authorized Official - Last Name:RANDALL
Authorized Official - Suffix:
Authorized Official - Credentials:DPM,AACFAS
Authorized Official - Phone:267-934-6996
Mailing Address - Street 1:28829 PUJOL ST APT 718
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92590-6710
Mailing Address - Country:US
Mailing Address - Phone:267-934-6996
Mailing Address - Fax:
Practice Address - Street 1:28829 PUJOL ST APT 718
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92590-6710
Practice Address - Country:US
Practice Address - Phone:267-934-6996
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-10
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle SurgeryGroup - Single Specialty