Provider Demographics
NPI:1083679328
Name:RANDALL, PAUL LLOYD JOHN (DC)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:LLOYD JOHN
Last Name:RANDALL
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 1:100 RUBY ST
Mailing Address - Street 2:#F
Mailing Address - City:TUMWATER
Mailing Address - State:WA
Mailing Address - Zip Code:98501-6724
Mailing Address - Country:US
Mailing Address - Phone:360-943-4797
Mailing Address - Fax:360-709-0542
Practice Address - Street 1:100 RUBY ST
Practice Address - Street 2:#F
Practice Address - City:TUMWATER
Practice Address - State:WA
Practice Address - Zip Code:98501-6724
Practice Address - Country:US
Practice Address - Phone:360-943-4797
Practice Address - Fax:360-709-0542
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00001228111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
T02780Medicare ID - Type Unspecified