Healthcare Provider Details

I. General information

NPI: 1134054950
Provider Name (Legal Business Name): RANDALL STARCK DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2026
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1082 BLACKBURN BLF
CHARLOTTESVILLE VA
22901-0608
US

IV. Provider business mailing address

1082 BLACKBURN BLF
CHARLOTTESVILLE VA
22901-0608
US

V. Phone/Fax

Practice location:
  • Phone: 630-802-0918
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2305213489
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: