Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | PT6020 | CA |
N | 2251C2600X | Cardiopulmonary | PT 6020 | CA |
NPI | 1851375083 |
---|---|
Provider Name | Randolph George Ice |
First Address | Murrieta, CA 92562-6177 |
Second Address | Murrieta, CA 92562-5987 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/12/2005 |
Last Update Date | 07/10/2009 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00PT60200 | BLUE SHIELD OF CALIFORNIA (01) | CA |
S00965 | (02) | CA |