Provider Demographics
NPI:1417912759
Name:ROTH, RANDALL LYNN (DC)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:LYNN
Last Name:ROTH
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 1:804 HIGDON FERRY RD
Mailing Address - Street 2:
Mailing Address - City:HOT SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:71913-6129
Mailing Address - Country:US
Mailing Address - Phone:501-881-4407
Mailing Address - Fax:501-881-4407
Practice Address - Street 1:804 HIGDON FERRY RD
Practice Address - Street 2:
Practice Address - City:HOT SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:71913-6129
Practice Address - Country:US
Practice Address - Phone:501-881-4407
Practice Address - Fax:501-881-4407
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2009-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1219111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR59741OtherBLUE CROSS BLUE SHIELD
T93026Medicare UPIN