Provider Demographics
NPI:1164565131
Name:PRUITT, RANDALL C (DC)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:C
Last Name:PRUITT
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 1:10327 E MARK LN
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85262-8909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4530 E RAY RD
Practice Address - Street 2:#150
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85044-6094
Practice Address - Country:US
Practice Address - Phone:480-503-3344
Practice Address - Fax:480-763-0417
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5660111NN0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NN0400XChiropractic ProvidersChiropractorNeurology