Provider Demographics
NPI:1245388651
Name:ROCHESTER, RANDALL JOHN (DC)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:JOHN
Last Name:ROCHESTER
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 1:733 DUNLAWTON AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127-4226
Mailing Address - Country:US
Mailing Address - Phone:386-760-0806
Mailing Address - Fax:386-788-1037
Practice Address - Street 1:733 DUNLAWTON AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127-4226
Practice Address - Country:US
Practice Address - Phone:386-767-8492
Practice Address - Fax:386-788-1037
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2018-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH5018111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL22129Medicare ID - Type Unspecified