Basic Information
| Provider Information | |||||||||
| NPI: | 1023192234 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RICKETTS | ||||||||
| FirstName: | RANDALL | ||||||||
| MiddleName: | VINCENT | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 26991 CROWN VALLEY PKWY | ||||||||
| Address2: | # 100 | ||||||||
| City: | MISSION VIEJO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926916528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9499233277 | ||||||||
| FaxNumber: | 8558125865 | ||||||||
| Practice Location | |||||||||
| Address1: | 26991 CROWN VALLEY PKWY | ||||||||
| Address2: | |||||||||
| City: | MISSION VIEJO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926916528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9495825430 | ||||||||
| FaxNumber: | 9493489513 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2006 | ||||||||
| LastUpdateDate: | 11/19/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 20A4956 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00AX49560 | 01 | CA | MEDICAL | OTHER |