Provider Demographics
NPI:1952664997
Name:WORTHINGTON, RANDALL JAEGER (CMT)
Entity Type:Individual
Prefix:MR
First Name:RANDALL
Middle Name:JAEGER
Last Name:WORTHINGTON
Suffix:
Gender:M
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6422 MAGNOLIA AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-2408
Mailing Address - Country:US
Mailing Address - Phone:951-581-3242
Mailing Address - Fax:
Practice Address - Street 1:6422 MAGNOLIA AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-2408
Practice Address - Country:US
Practice Address - Phone:951-581-3242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-22
Last Update Date:2012-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34725225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist