Provider Demographics
NPI:1639396237
Name:RANDALL HEPWORTH
Entity Type:Organization
Organization Name:RANDALL HEPWORTH
Other - Org Name:RIVER ROCK PEDIATRICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:CLAUD
Authorized Official - Last Name:HEPWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:916-404-2715
Mailing Address - Street 1:1000 RIVER ROCK DR
Mailing Address - Street 2:# 114
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95630-2093
Mailing Address - Country:US
Mailing Address - Phone:916-989-2086
Mailing Address - Fax:916-989-0367
Practice Address - Street 1:1000 RIVER ROCK DR
Practice Address - Street 2:# 114
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630-0367
Practice Address - Country:US
Practice Address - Phone:916-989-2086
Practice Address - Fax:916-989-0367
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG45570208000000X, 291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No291U00000XLaboratoriesClinical Medical LaboratoryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALAB14087FOtherOFFICE LAB
CAG455701Medicaid