Provider Demographics
NPI:1316023419
Name:RANDALL, ANDREW O (PT)
Entity Type:Individual
Prefix:MR
First Name:ANDREW
Middle Name:O
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 1:275 WISTERIA BLVD
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:30016-7208
Mailing Address - Country:US
Mailing Address - Phone:770-788-1963
Mailing Address - Fax:770-788-1963
Practice Address - Street 1:275 WISTERIA BLVD
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30016-7208
Practice Address - Country:US
Practice Address - Phone:770-788-1963
Practice Address - Fax:770-788-1963
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA3600225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist