Healthcare Provider Details

I. General information

NPI: 1174508121
Provider Name (Legal Business Name): CHRISTA DAWN RANDOLPH MPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2005
Last Update Date: 07/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

306 W MAIN ST
BRIDGEPORT WV
26330-1751
US

IV. Provider business mailing address

306 W MAIN ST
BRIDGEPORT WV
26330-1751
US

V. Phone/Fax

Practice location:
  • Phone: 304-842-3137
  • Fax: 304-842-3138
Mailing address:
  • Phone: 304-842-3137
  • Fax: 304-842-3138

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number002526
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number002526
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: