Provider Demographics
NPI:1952842742
Name:RANDALL, DAVID CHARLES (MPT)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:CHARLES
Last Name:RANDALL
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:527 AVENUE B
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32951-2216
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:527 AVENUE B
Practice Address - Street 2:
Practice Address - City:MELBOURNE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32951-2216
Practice Address - Country:US
Practice Address - Phone:321-482-4982
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-14
Last Update Date:2017-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT22170225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist