Provider Demographics
NPI:1164595179
Name:BOUCHARD, RANDAL SCOTT (DC)
Entity Type:Individual
Prefix:DR
First Name:RANDAL
Middle Name:SCOTT
Last Name:BOUCHARD
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:PO BOX 2817
Mailing Address - Street 2:
Mailing Address - City:KAYENTA
Mailing Address - State:AZ
Mailing Address - Zip Code:86033-2817
Mailing Address - Country:US
Mailing Address - Phone:928-697-2547
Mailing Address - Fax:928-697-2549
Practice Address - Street 1:1 CANYON DRIVE
Practice Address - Street 2:
Practice Address - City:KAYENTA
Practice Address - State:AZ
Practice Address - Zip Code:86033-2817
Practice Address - Country:US
Practice Address - Phone:928-697-2547
Practice Address - Fax:928-697-2549
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5801111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1050201OtherASHN
AZ2111887OtherCCN FIRST HEALTH
AZ218760-01OtherHMA
AZAZ0939060OtherBCBSAZ