Doctor Name: | GLEN RANDALL |
NPI Number: | 1427083807 |
Entity Type Code: | Individual (1) |
Gender: | M |
Credentials: | DC |
License Number: | CHIA-912 |
Business Practice Address: | 1598 Delphic Way Ste A2 Pocatello, ID - 832012200 |
Business Phone Number: | 2082320220 |
Business Fax Number: | |
Mailing Address: | 1598 Delphic Way Ste A2, POCATELLO |
State: | ID |
Postal Code: | 832012200 |
Phone Number: | |
Fax Number: | |
NPI Enumeration Date: | 07/12/2006 |
NPI Last Update Date: | 07/09/2007 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 111N00000X |
License Number: | CHIA-912 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | ID |
Taxonomy Type: | Chiropractic Providers |
Taxonomy Classification: | Chiropractor |
Taxonomy Specialization: | |
Taxonomy Definition: | A provider qualified by a Doctor of Chiropractic (D.C.), licensed by the State and who practices chiropractic medicine -that discipline within the healing arts which deals with the nervous system and its relationship to the spinal column and its interrelationship with other body systems. |