Provider Demographics
NPI:1235172826
Name:RANDALL, KIRK CHRISTOPHER (PT)
Entity Type:Individual
Prefix:MR
First Name:KIRK
Middle Name:CHRISTOPHER
Last Name:RANDALL
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3753 BASSWOOD DR SW
Mailing Address - Street 2:
Mailing Address - City:GRANDVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49418-2003
Mailing Address - Country:US
Mailing Address - Phone:616-340-6407
Mailing Address - Fax:616-301-2882
Practice Address - Street 1:3753 BASSWOOD DR SW
Practice Address - Street 2:
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418-2003
Practice Address - Country:US
Practice Address - Phone:616-340-6407
Practice Address - Fax:616-301-2882
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-13
Last Update Date:2008-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501005678225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI7171532OtherAETNA
MI0P13970Medicare PIN