Provider Demographics
NPI:1629115001
Name:BOUTWELL, JOHN RANDALL (DC,BCAO)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:RANDALL
Last Name:BOUTWELL
Suffix:
Gender:M
Credentials:DC,BCAO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3665 WHEELER RD
Mailing Address - Street 2:SUITE 2A
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-6603
Mailing Address - Country:US
Mailing Address - Phone:706-860-8717
Mailing Address - Fax:706-860-1341
Practice Address - Street 1:3665 WHEELER RD
Practice Address - Street 2:SUITE 2A
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-6603
Practice Address - Country:US
Practice Address - Phone:706-860-8717
Practice Address - Fax:706-860-1341
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2015-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR001886111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA35ZCFLNOtherPTAN
GAT97507Medicare UPIN