Healthcare Provider Details

I. General information

NPI: 1588740674
Provider Name (Legal Business Name): RANDOLPH CLARK DAVIS D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/31/2006
Last Update Date: 09/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 BAWDEN ST SUITE 306
KETCHIKAN AK
99901-6503
US

IV. Provider business mailing address

320 BAWDEN ST SUITE 306
KETCHIKAN AK
99901-6503
US

V. Phone/Fax

Practice location:
  • Phone: 907-225-6815
  • Fax: 907-225-5767
Mailing address:
  • Phone: 907-225-6815
  • Fax: 907-225-5767

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number149
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: