Provider Demographics
NPI:1245315746
Name:RANDALL, PETER RAYMOND (DC)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:RAYMOND
Last Name:RANDALL
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 1:2202 W CHARLESTON BLVD STE 10
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102-2229
Mailing Address - Country:US
Mailing Address - Phone:702-385-5535
Mailing Address - Fax:702-754-2574
Practice Address - Street 1:2202 W CHARLESTON BLVD STE 10
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102
Practice Address - Country:US
Practice Address - Phone:702-385-5535
Practice Address - Fax:702-754-2574
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2018-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVB01226111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
660483Medicare UPIN
NY509948Medicare ID - Type Unspecified