=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245315746
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PETER RAYMOND RANDALL DC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/25/2006
-----------------------------------------------------
Last Update Date | 06/08/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2202 W CHARLESTON BLVD STE 10
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-385-5535
-----------------------------------------------------
Fax | 702-754-2574
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2202 W CHARLESTON BLVD STE 10
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89102-2229
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-385-5535
-----------------------------------------------------
Fax | 702-754-2574
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | B01226
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------