Provider Demographics
NPI:1558478982
Name:RANDALL, GEORGE WILLIAM (DC)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:WILLIAM
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 1:703 W KING STREET
Mailing Address - Street 2:
Mailing Address - City:KINGS MOUNTAIN
Mailing Address - State:NC
Mailing Address - Zip Code:28086
Mailing Address - Country:US
Mailing Address - Phone:704-739-7776
Mailing Address - Fax:704-739-7776
Practice Address - Street 1:703 W KING STREET
Practice Address - Street 2:
Practice Address - City:KINGS MOUNTAIN
Practice Address - State:NC
Practice Address - Zip Code:28086
Practice Address - Country:US
Practice Address - Phone:704-739-7776
Practice Address - Fax:704-739-7776
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1865111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8908687Medicaid
NC08687OtherBCBS
NC5109252OtherAETNA
NC5109252OtherAETNA
U32323Medicare UPIN