MEDICARE: DR. RANDALL CRAIG STARK D.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	DC20409	CA

General Provider Information

NPI Number	:	1568674737
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RANDALL CRAIG STARK D.C.

Provider Business Mailing Address
First Line	:	4132 KATELLA AVE STE 102
Second Line	:
City	:	LOS ALAMITOS
State	:	CA
Zip	:	90720-3491
Country	:	US
Telephone Number	:	562-493-4473
Fax Number	:	562-493-4824

Provider Business Practice Location Address
First Line	:	4132 KATELLA AVE STE 102
Second Line	:
City	:	LOS ALAMITOS
State	:	CA
Zip	:	90720-3491
Country	:	US
Telephone Number	:	562-493-4473
Fax Number	:	562-493-4824

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/03/2007
Last Update Date	:	07/08/2007

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