Provider Demographics
NPI:1215098975
Name:RANDEL, ROBERT BURR (DC)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:BURR
Last Name:RANDEL
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 1:3042 ROSA DEL VILLA DR
Mailing Address - Street 2:
Mailing Address - City:GULF BREEZE
Mailing Address - State:FL
Mailing Address - Zip Code:32563-2650
Mailing Address - Country:US
Mailing Address - Phone:850-934-1919
Mailing Address - Fax:850-934-1919
Practice Address - Street 1:3417 GULF BREEZE PKWY
Practice Address - Street 2:
Practice Address - City:GULF BREEZE
Practice Address - State:FL
Practice Address - Zip Code:32563-3476
Practice Address - Country:US
Practice Address - Phone:850-934-1919
Practice Address - Fax:850-934-1927
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCHOOO4806111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLT84482Medicare UPIN
FL70570Medicare ID - Type Unspecified