Provider Demographics
NPI:1851697833
Name:RANDOLPH S LAWRENCE MD A MEDICAL CORP
Entity Type:Organization
Organization Name:RANDOLPH S LAWRENCE MD A MEDICAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MGR. - PART OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:ROMERO
Authorized Official - Last Name:LAWRENCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-434-0811
Mailing Address - Street 1:1320 LAS TABLAS RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:TEMPLETON
Mailing Address - State:CA
Mailing Address - Zip Code:93465-9711
Mailing Address - Country:US
Mailing Address - Phone:805-434-0811
Mailing Address - Fax:805-434-3455
Practice Address - Street 1:1320 LAS TABLAS RD
Practice Address - Street 2:SUITE C
Practice Address - City:TEMPLETON
Practice Address - State:CA
Practice Address - Zip Code:93465-9711
Practice Address - Country:US
Practice Address - Phone:805-434-0811
Practice Address - Fax:805-434-3455
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-08
Last Update Date:2011-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG32240174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA91420Medicare UPIN