Provider Demographics
NPI:1790225928
Name:GUTIERRE, RANDOLPH
Entity Type:Individual
Prefix:
First Name:RANDOLPH
Middle Name:
Last Name:GUTIERRE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3721 MENTONE AVE APT 7
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90034-6578
Mailing Address - Country:US
Mailing Address - Phone:310-621-9882
Mailing Address - Fax:
Practice Address - Street 1:3721 MENTONE AVE APT 7
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90034-6578
Practice Address - Country:US
Practice Address - Phone:310-621-9882
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-07
Last Update Date:2017-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator