Provider Demographics
NPI:1083355143
Name:RANDOLPH, NICHOLAS RYAN (DC)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:RYAN
Last Name:RANDOLPH
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 1:1764 E BROADWAY APT 1
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90802-3711
Mailing Address - Country:US
Mailing Address - Phone:313-378-6702
Mailing Address - Fax:
Practice Address - Street 1:7071 WARNER AVE STE C
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92647-5444
Practice Address - Country:US
Practice Address - Phone:313-378-6702
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-05
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34913111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor