Provider Demographics
NPI:1073606877
Name:BOIVIN, RANDAL ROBERT (DC)
Entity type:Individual
Prefix:
First Name:RANDAL
Middle Name:ROBERT
Last Name:BOIVIN
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 1:12590 PERRY HWY STE 200
Mailing Address - Street 2:
Mailing Address - City:WEXFORD
Mailing Address - State:PA
Mailing Address - Zip Code:15090-1550
Mailing Address - Country:US
Mailing Address - Phone:724-799-8004
Mailing Address - Fax:724-799-8393
Practice Address - Street 1:12590 PERRY HWY STE 200
Practice Address - Street 2:
Practice Address - City:WEXFORD
Practice Address - State:PA
Practice Address - Zip Code:15090-1550
Practice Address - Country:US
Practice Address - Phone:724-799-8004
Practice Address - Fax:247-799-8393
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2023-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX010482-1111NN0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NN0400XChiropractic ProvidersChiropractorNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYU92425Medicare UPIN
NYRB1576Medicare PIN