Provider Demographics
NPI:1407103583
Name:LINDSTROM, RANDALL CLYDE (DC)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:CLYDE
Last Name:LINDSTROM
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 1:2294 OTRANTO ROAD
Mailing Address - Street 2:
Mailing Address - City:N. CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406
Mailing Address - Country:US
Mailing Address - Phone:843-225-2550
Mailing Address - Fax:
Practice Address - Street 1:2294 OTRANTO RD
Practice Address - Street 2:
Practice Address - City:N CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-9603
Practice Address - Country:US
Practice Address - Phone:843-225-2550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-08
Last Update Date:2012-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3755111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor