Provider Demographics
NPI:1417092057
Name:RANDALL, KENNETH EDWIN (PT)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:EDWIN
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 1:4502 E 41ST ST
Mailing Address - Street 2:STE 2J30
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-2553
Mailing Address - Country:US
Mailing Address - Phone:918-660-3276
Mailing Address - Fax:918-660-3297
Practice Address - Street 1:1111 S SAINT LOUIS AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74120-5440
Practice Address - Country:US
Practice Address - Phone:918-619-4600
Practice Address - Fax:918-619-4601
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1372225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist