Provider Demographics
NPI:1891907937
Name:MADDOX, RANDALL GARY (PT)
Entity Type:Individual
Prefix:MR
First Name:RANDALL
Middle Name:GARY
Last Name:MADDOX
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9555 HUMPHREY LN
Mailing Address - Street 2:
Mailing Address - City:REDWOOD VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95470-9783
Mailing Address - Country:US
Mailing Address - Phone:707-485-0169
Mailing Address - Fax:
Practice Address - Street 1:275 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482-4531
Practice Address - Country:US
Practice Address - Phone:707-463-7346
Practice Address - Fax:707-463-7569
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 7779225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist