Provider Demographics
NPI:1174620751
Name:RANDALL, RICHARD STANLEY (PT)
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:STANLEY
Last Name:RANDALL
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2175 N ALMA SCHOOL RD STE A106
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-2802
Mailing Address - Country:US
Mailing Address - Phone:480-730-5656
Mailing Address - Fax:480-730-9969
Practice Address - Street 1:2175 N ALMA SCHOOL RD STE A106
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-2802
Practice Address - Country:US
Practice Address - Phone:480-730-5656
Practice Address - Fax:480-730-9969
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRPT 569225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZRPT 569Medicare ID - Type UnspecifiedPHYSICAL THERAPY