Basic Information
| Provider Information | |||||||||
| NPI: | 1174564009 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RANDA BASCHARON D.O., INC | ||||||||
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| OtherOrganizationName: | ORTHOPEDIC & SPORTS MEDICINE INSTITUTE OF LAS VEGAS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4132 S RAINBOW BLVD | ||||||||
| Address2: | #393 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891033106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7025960036 | ||||||||
| FaxNumber: | 7029477792 | ||||||||
| Practice Location | |||||||||
| Address1: | 6850 N DURANGO DR | ||||||||
| Address2: | #218 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891494595 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7029477790 | ||||||||
| FaxNumber: | 7029477792 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2006 | ||||||||
| LastUpdateDate: | 02/18/2010 | ||||||||
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| AuthorizedOfficialLastName: | BASCHARON | ||||||||
| AuthorizedOfficialFirstName: | RANDA | ||||||||
| AuthorizedOfficialMiddleName: | AMIN | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER PRES SEC ETC | ||||||||
| AuthorizedOfficialTelephone: | 7025960036 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 20A8358 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XX0005X | 1103 | NV | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine | 207XX0005X | 20A8358 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine | 207X00000X | 1103 | NV | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | XTE006922 | 01 | CA | CALIF MEDI-CAL | OTHER | 100503044 | 05 | NV | MEDICAID |