Provider Demographics
NPI:1013265214
Name:RANDALL G. SHUE D.O. INC.
Entity Type:Organization
Organization Name:RANDALL G. SHUE D.O. INC.
Other - Org Name:LA PROCEDURE CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:G
Authorized Official - Last Name:SHUE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:323-268-3491
Mailing Address - Street 1:4055 E OLYMPIC BLVD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90023-3345
Mailing Address - Country:US
Mailing Address - Phone:323-268-3491
Mailing Address - Fax:
Practice Address - Street 1:4055 E OLYMPIC BLVD
Practice Address - Street 2:SUITE 210
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90023-3345
Practice Address - Country:US
Practice Address - Phone:323-268-3491
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RANDALL G. SHUE D.O. INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-08-17
Last Update Date:2012-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A5142261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX51420Medicaid
CA00AX51420Medicaid