Provider Demographics
NPI:1386658680
Name:HARATYK, RANDALL L (PT)
Entity Type:Individual
Prefix:MR
First Name:RANDALL
Middle Name:L
Last Name:HARATYK
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 RINCON RD
Mailing Address - Street 2:
Mailing Address - City:CORRALES
Mailing Address - State:NM
Mailing Address - Zip Code:87048-7651
Mailing Address - Country:US
Mailing Address - Phone:505-899-1509
Mailing Address - Fax:505-890-7380
Practice Address - Street 1:600 RINCON RD
Practice Address - Street 2:
Practice Address - City:CORRALES
Practice Address - State:NM
Practice Address - Zip Code:87048-7651
Practice Address - Country:US
Practice Address - Phone:505-899-1509
Practice Address - Fax:505-890-7380
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2240225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMOOQ464OtherBCBS PROVIDER #