Provider Demographics
NPI:1629130265
Name:WEINER, RANDY (DC)
Entity Type:Individual
Prefix:DR
First Name:RANDY
Middle Name:
Last Name:WEINER
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 1:493 ROUTE 304
Mailing Address - Street 2:
Mailing Address - City:NEW CITY
Mailing Address - State:NY
Mailing Address - Zip Code:10956
Mailing Address - Country:US
Mailing Address - Phone:845-634-0621
Mailing Address - Fax:845-634-0669
Practice Address - Street 1:493 ROUTE 304
Practice Address - Street 2:
Practice Address - City:NEW CITY
Practice Address - State:NY
Practice Address - Zip Code:10956
Practice Address - Country:US
Practice Address - Phone:845-634-0621
Practice Address - Fax:845-634-0669
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2010-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX0035161111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
X20221Medicare ID - Type Unspecified