Provider Demographics
NPI:1346252046
Name:MAXWELL, RANDY BERNARD (DC)
Entity Type:Individual
Prefix:DR
First Name:RANDY
Middle Name:BERNARD
Last Name:MAXWELL
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 1:1512 N WALKER ST
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:WV
Mailing Address - Zip Code:24740-2639
Mailing Address - Country:US
Mailing Address - Phone:304-487-8985
Mailing Address - Fax:304-425-1680
Practice Address - Street 1:1512 N WALKER ST
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:WV
Practice Address - Zip Code:24740-2639
Practice Address - Country:US
Practice Address - Phone:304-487-8985
Practice Address - Fax:304-425-1680
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV850111N00000X
VA0104556437111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor