Healthcare Provider Details

I. General information

NPI: 1164457321
Provider Name (Legal Business Name): TERRY L RANDALL DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 07/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 MEDPARK DR
SOMERSET KY
42503-2734
US

IV. Provider business mailing address

175 MEDPARK DR
SOMERSET KY
42503-2734
US

V. Phone/Fax

Practice location:
  • Phone: 606-679-1761
  • Fax: 606-678-0971
Mailing address:
  • Phone: 606-679-1761
  • Fax: 606-678-0971

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number003180
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT361
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: