Provider Demographics
NPI:1104988591
Name:RANDALL, RUSSELL JAMES (DC)
Entity type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:JAMES
Last Name:RANDALL
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 1:227 COLFAX AVENUE
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945
Mailing Address - Country:US
Mailing Address - Phone:530-273-7988
Mailing Address - Fax:530-273-7993
Practice Address - Street 1:227 COLFAX AVENUE
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945
Practice Address - Country:US
Practice Address - Phone:530-273-7988
Practice Address - Fax:530-273-7993
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2012-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC0109140111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0109140Medicaid
CA0109140Medicare ID - Type Unspecified
CA0109140Medicaid