Provider Demographics
NPI:1790322964
Name:BOEGLIN, RANDY LEE JR
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:LEE
Last Name:BOEGLIN
Suffix:JR
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 1:7334 CASCADE CT
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-6732
Mailing Address - Country:US
Mailing Address - Phone:714-833-8955
Mailing Address - Fax:
Practice Address - Street 1:7334 CASCADE CT
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-6732
Practice Address - Country:US
Practice Address - Phone:714-833-8955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-05
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider