Basic Information
| Provider Information | |||||||||
| NPI: | 1114393139 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RANDEL | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | THOMAS | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 291228 | ||||||||
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| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782291828 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2106805033 | ||||||||
| FaxNumber: | 2106806094 | ||||||||
| Practice Location | |||||||||
| Address1: | 1901 BABCOCK RD STE 304 | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782294546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2106805033 | ||||||||
| FaxNumber: | 2106806094 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2015 | ||||||||
| LastUpdateDate: | 08/13/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 1262588 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.