MEDICARE: DR. RANDALL WARREN MARTIN D.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	DC 5932	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	605953	OTHER	TX	BLUECROSS BLUESHIELD

General Provider Information

NPI Number	:	1639218415
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RANDALL WARREN MARTIN D.C.

Provider Business Mailing Address
First Line	:	5400 OVERRIDGE DR
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76017-1249
Country	:	US
Telephone Number	:	817-795-5855
Fax Number	:	817-795-9330

Provider Business Practice Location Address
First Line	:	3343 W PIONEER PKWY
Second Line	:
City	:	PANTEGO
State	:	TX
Zip	:	76013-4603
Country	:	US
Telephone Number	:	817-795-5855
Fax Number	:	817-795-9330

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/06/2007
Last Update Date	:	07/08/2007

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