=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669942637
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RANDY KLOSS DC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/03/2018
-----------------------------------------------------
Last Update Date | 12/03/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 224 ONEIL CT
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29223-7649
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-788-8831
-----------------------------------------------------
Fax | 803-788-8846
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 224 ONEIL CT
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29223-7649
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-788-8831
-----------------------------------------------------
Fax | 803-788-8846
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 4380
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------