Healthcare Provider Details

I. General information

NPI: 1972594026
Provider Name (Legal Business Name): MICHAEL P RANDALL D.C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/28/2005
Last Update Date: 08/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12150 E TURQUOISE CIR
DEWEY AZ
86327-5739
US

IV. Provider business mailing address

12150 E TURQUOISE CIR
DEWEY AZ
86327-5739
US

V. Phone/Fax

Practice location:
  • Phone: 928-775-7221
  • Fax: 928-775-7223
Mailing address:
  • Phone: 928-775-7221
  • Fax: 928-775-7223

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number4544
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: