Provider Demographics
NPI:1770691891
Name:POORTVLIET, RANDEE MARISA
Entity type:Individual
Prefix:DR
First Name:RANDEE
Middle Name:MARISA
Last Name:POORTVLIET
Suffix:
Gender:F
Credentials:
Other - Prefix:DR
Other - First Name:RANDEE
Other - Middle Name:MARISA
Other - Last Name:WARD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:405 W OAK ST
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76201-9039
Mailing Address - Country:US
Mailing Address - Phone:940-484-8894
Mailing Address - Fax:940-484-1389
Practice Address - Street 1:405 W OAK ST
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76201-9039
Practice Address - Country:US
Practice Address - Phone:940-484-8894
Practice Address - Fax:940-484-1389
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX7880111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8857MOMedicare ID - Type Unspecified
TX484535Medicare UPIN