Provider Demographics
NPI:1902912181
Name:CELESTE RANDALL PHYSICAL THERAPY, INC.
Entity Type:Organization
Organization Name:CELESTE RANDALL PHYSICAL THERAPY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:CELESTE
Authorized Official - Middle Name:
Authorized Official - Last Name:RANDALL
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:818-784-3096
Mailing Address - Street 1:5535 BALBOA BLVD
Mailing Address - Street 2:#216
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316-1516
Mailing Address - Country:US
Mailing Address - Phone:818-784-3096
Mailing Address - Fax:818-786-3097
Practice Address - Street 1:5535 BALBOA BLVD
Practice Address - Street 2:#216
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316-1516
Practice Address - Country:US
Practice Address - Phone:818-784-3096
Practice Address - Fax:818-786-3097
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2007-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT8407225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT8407AMedicare PIN