Provider Demographics
NPI:1518982990
Name:STERN, RANDOLPH PETER (DC)
Entity Type:Individual
Prefix:DR
First Name:RANDOLPH
Middle Name:PETER
Last Name:STERN
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 1:1603 AVIATION BLVD
Mailing Address - Street 2:SUITE E
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90278-2858
Mailing Address - Country:US
Mailing Address - Phone:310-376-5678
Mailing Address - Fax:310-376-3060
Practice Address - Street 1:1603 AVIATION BLVD
Practice Address - Street 2:SUITE E
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90278-2858
Practice Address - Country:US
Practice Address - Phone:310-376-5678
Practice Address - Fax:310-376-3060
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC 15505111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC 15505Medicare ID - Type UnspecifiedMEDICARE
CADC 15505Medicare UPIN