Provider Demographics
NPI:1770532327
Name:RANDOLPH, KENNETH JOEL (DC)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:JOEL
Last Name:RANDOLPH
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 1:819 MIMOSA PARK RD
Mailing Address - Street 2:
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35405-4839
Mailing Address - Country:US
Mailing Address - Phone:205-752-7503
Mailing Address - Fax:205-752-7513
Practice Address - Street 1:819 MIMOSA PARK RD
Practice Address - Street 2:
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35405-4839
Practice Address - Country:US
Practice Address - Phone:205-752-7503
Practice Address - Fax:205-752-7513
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1931111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL60625Medicare UPIN