Provider Demographics
NPI:1780626689
Name:PENN, RANDOPLH (DC)
Entity type:Individual
Prefix:DR
First Name:RANDOPLH
Middle Name:
Last Name:PENN
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 1:1737 SPRING ARBOR ROAD SUITE 191
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49203-2701
Mailing Address - Country:US
Mailing Address - Phone:517-784-7443
Mailing Address - Fax:517-784-0165
Practice Address - Street 1:1905 HORTON RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49203-5519
Practice Address - Country:US
Practice Address - Phone:517-784-7443
Practice Address - Fax:517-784-0165
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-12
Last Update Date:2017-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301005819111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0C05004Medicare UPIN