Provider Demographics
NPI:1487848750
Name:JOHN T RANDOLPH JR DC PC
Entity Type:Organization
Organization Name:JOHN T RANDOLPH JR DC PC
Other - Org Name:KEY HEALTH CHIROPRACTIC
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:T
Authorized Official - Last Name:RANDOLPH
Authorized Official - Suffix:JR
Authorized Official - Credentials:DO
Authorized Official - Phone:713-451-1784
Mailing Address - Street 1:10223 W BROADWAY ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77584-7881
Mailing Address - Country:US
Mailing Address - Phone:713-436-2600
Mailing Address - Fax:713-436-2645
Practice Address - Street 1:10223 W BROADWAY ST
Practice Address - Street 2:SUITE C
Practice Address - City:PEARLAND
Practice Address - State:TX
Practice Address - Zip Code:77584-7881
Practice Address - Country:US
Practice Address - Phone:713-436-2600
Practice Address - Fax:713-436-2645
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-30
Last Update Date:2008-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDC5911111N00000X
TX5911111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
8F0051Medicare UPIN
00099ZMedicare PIN
TX8F0551Medicare UPIN