Provider Demographics
NPI:1427007178
Name:VINCEK, RANDALL (PT, OCS)
Entity Type:Individual
Prefix:MR
First Name:RANDALL
Middle Name:
Last Name:VINCEK
Suffix:
Gender:M
Credentials:PT, OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 BRIGHAM RD
Mailing Address - Street 2:
Mailing Address - City:FREDONIA
Mailing Address - State:NY
Mailing Address - Zip Code:14063-1000
Mailing Address - Country:US
Mailing Address - Phone:716-679-7447
Mailing Address - Fax:716-679-7446
Practice Address - Street 1:12 BRIGHAM RD
Practice Address - Street 2:
Practice Address - City:FREDONIA
Practice Address - State:NY
Practice Address - Zip Code:14063-1000
Practice Address - Country:US
Practice Address - Phone:716-679-7447
Practice Address - Fax:716-679-7446
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013650225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000623193006OtherBLUE CROSS/BLUE SHIELD
NY00025972901OtherUNIVERA
NY821432OtherMANAGED PHYSICAL NETWORK
NY9310590OtherINDEPENDENT HEALTH
NYAA1277Medicare ID - Type Unspecified