Provider Demographics
NPI:1215579230
Name:VALLEMBOIS, RANDY S (CPO)
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:S
Last Name:VALLEMBOIS
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2039 N FINE AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93727-1512
Mailing Address - Country:US
Mailing Address - Phone:559-251-5557
Mailing Address - Fax:559-251-5559
Practice Address - Street 1:2039 N FINE AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93727-1512
Practice Address - Country:US
Practice Address - Phone:559-251-5557
Practice Address - Fax:559-251-5559
Is Sole Proprietor?:No
Enumeration Date:2019-10-10
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAXC0197370Medicaid