Provider Demographics
NPI:1558442301
Name:RANDALL, MICAH L (DC)
Entity Type:Individual
Prefix:DR
First Name:MICAH
Middle Name:L
Last Name:RANDALL
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 1:12539 W HORSHAM DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-7392
Mailing Address - Country:US
Mailing Address - Phone:208-362-3200
Mailing Address - Fax:
Practice Address - Street 1:10108 W OVERLAND RD
Practice Address - Street 2:SUITE B
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-1428
Practice Address - Country:US
Practice Address - Phone:208-323-8600
Practice Address - Fax:208-323-8603
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-1015111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor