Provider Demographics
NPI:1649471046
Name:CONGER, RANDALL JAMES (DC)
Entity type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:JAMES
Last Name:CONGER
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 1:101 STONE VILLAGE DRIVE
Mailing Address - Street 2:
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29708-6489
Mailing Address - Country:US
Mailing Address - Phone:803-802-5322
Mailing Address - Fax:803-802-5665
Practice Address - Street 1:101 STONE VILLAGE DRIVE
Practice Address - Street 2:
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29708-6489
Practice Address - Country:US
Practice Address - Phone:803-802-5322
Practice Address - Fax:803-802-5665
Is Sole Proprietor?:No
Enumeration Date:2007-05-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2295111N00000X
NC1915111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCCH1916Medicaid
SCCH1916Medicaid