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General NPI Number Information
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NPI Number | 1306930979
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Entity Type | Individual
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Provider Name | CONNY CHRISTL RANDOLPH PHYSICAL THERAPIST
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Gender | Female
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Dates
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Enumeration Date | 10/03/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 808 HWY 98 BYPASS
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City | COLUMBIA
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State | MS
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Zip | 39429-0429
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Country | US
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Telephone | 601-731-1140
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Fax | 601-731-1148
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Provider Business Mailing Address
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Address Line | 571 PICKWICK ROAD
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City | FOXWORTH
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State | MS
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Zip | 39483
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Country | US
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Telephone | 601-736-6617
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | PT1635
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License Number State | MS
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