Provider Demographics
NPI:1003804576
Name:DAVIS, RANDALL GREGG (DC)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:GREGG
Last Name:DAVIS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 N ARKANSAS AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72801-2936
Mailing Address - Country:US
Mailing Address - Phone:479-968-7890
Mailing Address - Fax:479-968-7890
Practice Address - Street 1:1000 N ARKANSAS AVE
Practice Address - Street 2:SUITE A
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72801-2936
Practice Address - Country:US
Practice Address - Phone:479-968-7890
Practice Address - Fax:479-968-7890
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR893111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
T20577Medicare UPIN
59136Medicare ID - Type Unspecified