Provider Demographics
NPI:1619912144
Name:RANDALL SUNDERLAND
Entity Type:Organization
Organization Name:RANDALL SUNDERLAND
Other - Org Name:MATRIX REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:SUNDERLAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:830-768-2582
Mailing Address - Street 1:707 E 17TH ST
Mailing Address - Street 2:
Mailing Address - City:DEL RIO
Mailing Address - State:TX
Mailing Address - Zip Code:78840-7817
Mailing Address - Country:US
Mailing Address - Phone:830-768-2582
Mailing Address - Fax:830-768-0992
Practice Address - Street 1:707 E 17TH ST
Practice Address - Street 2:
Practice Address - City:DEL RIO
Practice Address - State:TX
Practice Address - Zip Code:78840-7817
Practice Address - Country:US
Practice Address - Phone:830-768-2582
Practice Address - Fax:830-768-0992
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-18
Last Update Date:2007-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
676507Medicare PIN