Provider Demographics
NPI:1174627418
Name:RANDOLPH CHIROPRACTIC CLINIC
Entity type:Organization
Organization Name:RANDOLPH CHIROPRACTIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OF BUSINESS
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:J
Authorized Official - Last Name:RANDOLPH
Authorized Official - Suffix:
Authorized Official - Credentials:CHIROPRACTOR DC
Authorized Official - Phone:205-468-3464
Mailing Address - Street 1:PO BOX 370
Mailing Address - Street 2:
Mailing Address - City:GUIN
Mailing Address - State:AL
Mailing Address - Zip Code:35563
Mailing Address - Country:US
Mailing Address - Phone:205-468-3464
Mailing Address - Fax:205-468-3724
Practice Address - Street 1:7596 US HWY 43
Practice Address - Street 2:
Practice Address - City:GUIN
Practice Address - State:AL
Practice Address - Zip Code:35563
Practice Address - Country:US
Practice Address - Phone:205-468-3464
Practice Address - Fax:205-468-3724
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-08
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1931111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
51003438OtherBCBS
U93456Medicare UPIN