Provider Demographics
NPI:1346387917
Name:WONDERLICH, RANDY (DC)
Entity Type:Individual
Prefix:DR
First Name:RANDY
Middle Name:
Last Name:WONDERLICH
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 1:90 GRAPEVINE HWY
Mailing Address - Street 2:
Mailing Address - City:HURST
Mailing Address - State:TX
Mailing Address - Zip Code:76054-2299
Mailing Address - Country:US
Mailing Address - Phone:817-281-2991
Mailing Address - Fax:817-428-6617
Practice Address - Street 1:90 GRAPEVINE HWY
Practice Address - Street 2:
Practice Address - City:HURST
Practice Address - State:TX
Practice Address - Zip Code:76054-2299
Practice Address - Country:US
Practice Address - Phone:817-281-2991
Practice Address - Fax:817-428-6617
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2020-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5917111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX4296256OtherAETNA PROVIDER #
TX607098OtherBLUE CROSS PROVIDER #
TX607098OtherBLUE CROSS PROVIDER #
TX603569Medicare ID - Type Unspecified