Provider Demographics
NPI:1851375083
Name:ICE, RANDOLPH GEORGE (RPT)
Entity Type:Individual
Prefix:
First Name:RANDOLPH
Middle Name:GEORGE
Last Name:ICE
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24630 WASHINGTON AVE
Mailing Address - Street 2:STE 200
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562-6177
Mailing Address - Country:US
Mailing Address - Phone:951-696-9353
Mailing Address - Fax:951-973-7216
Practice Address - Street 1:25150 HANCOCK AVE
Practice Address - Street 2:STE 100
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562-5987
Practice Address - Country:US
Practice Address - Phone:951-698-7720
Practice Address - Fax:951-698-7451
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2009-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT6020225100000X
CAPT 60202251C2600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251C2600XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistCardiopulmonary
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00PT60200OtherBLUE SHIELD OF CALIFORNIA
CA00PT60200Medicare PIN
CA00PT60200OtherBLUE SHIELD OF CALIFORNIA