Provider Demographics
NPI:1619973286
Name:KURTZ, RANDALL L (DC)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:L
Last Name:KURTZ
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:PO BOX 707
Mailing Address - Street 2:
Mailing Address - City:ST MARYS
Mailing Address - State:PA
Mailing Address - Zip Code:15857-0707
Mailing Address - Country:US
Mailing Address - Phone:814-781-7117
Mailing Address - Fax:814-781-3490
Practice Address - Street 1:116 N SAINT MARYS ST
Practice Address - Street 2:
Practice Address - City:ST MARYS
Practice Address - State:PA
Practice Address - Zip Code:15857-1236
Practice Address - Country:US
Practice Address - Phone:814-781-7117
Practice Address - Fax:814-781-3490
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC01367L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA115995Medicare ID - Type Unspecified
PA368645Medicare ID - Type Unspecified