MEDICARE: RANDOUR CHIROPRACTIC CLINIC P.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	DC009323	PA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1914315	OTHER	PA	SUBMITTER ID- MEDICARE

General Provider Information

NPI Number	:	1497848642
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RANDOUR CHIROPRACTIC CLINIC P.C.

Provider Business Mailing Address
First Line	:	1100 WASHINGTON AVE
Second Line	:	STE. 100
City	:	CARNEGIE
State	:	PA
Zip	:	15106-3614
Country	:	US
Telephone Number	:	412-279-4040
Fax Number	:

Provider Business Practice Location Address
First Line	:	1100 WASHINGTON AVE
Second Line	:	STE. 100
City	:	CARNEGIE
State	:	PA
Zip	:	15106-3614
Country	:	US
Telephone Number	:	412-279-4040
Fax Number	:	412-279-4041

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	DR. JAMES LLOYD GOODGE IV
Credential	:	DC
Telephone Number	:	412-279-4040

Provider Enumeration Date	:	10/02/2006
Last Update Date	:	02/27/2013

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