Provider Demographics
NPI:1033207535
Name:ROBERTS, RANDALL THOMAS (DC)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:THOMAS
Last Name:ROBERTS
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 1:1240 E HIGHWAY 193
Mailing Address - Street 2:SUITE G8
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84040-8544
Mailing Address - Country:US
Mailing Address - Phone:801-771-2200
Mailing Address - Fax:801-771-2201
Practice Address - Street 1:1240 E HIGHWAY 193
Practice Address - Street 2:SUITE G8
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84040-8544
Practice Address - Country:US
Practice Address - Phone:801-771-2200
Practice Address - Fax:801-771-2201
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT165944-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor