Provider Demographics
NPI:1609386853
Name:RANDY WHITESIDE PROSTHETICS LLC
Entity Type:Organization
Organization Name:RANDY WHITESIDE PROSTHETICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITESIDE
Authorized Official - Suffix:
Authorized Official - Credentials:CP
Authorized Official - Phone:602-596-4010
Mailing Address - Street 1:1190 E MISSOURI AVE STE 190
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85014-2736
Mailing Address - Country:US
Mailing Address - Phone:602-596-1040
Mailing Address - Fax:480-212-5944
Practice Address - Street 1:1190 E MISSOURI AVE STE 190
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85014-2736
Practice Address - Country:US
Practice Address - Phone:602-596-1040
Practice Address - Fax:480-212-5944
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-02
Last Update Date:2017-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetistGroup - Single Specialty