Provider Demographics
NPI:1154603108
Name:RANDEL B. WING DOM PC
Entity type:Organization
Organization Name:RANDEL B. WING DOM PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RANDEL
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:WING
Authorized Official - Suffix:
Authorized Official - Credentials:LAC, DOM, NMD
Authorized Official - Phone:719-447-0046
Mailing Address - Street 1:2812 W COLORADO AVE
Mailing Address - Street 2:STE 106
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80904-2470
Mailing Address - Country:US
Mailing Address - Phone:719-447-0046
Mailing Address - Fax:719-447-4645
Practice Address - Street 1:2812 W COLORADO AVE
Practice Address - Street 2:STE 106
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80904-2470
Practice Address - Country:US
Practice Address - Phone:719-447-0046
Practice Address - Fax:719-447-4645
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-15
Last Update Date:2011-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO392171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty