Provider Demographics
NPI:1386759728
Name:HURT, RANDALL (DC)
Entity type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:
Last Name:HURT
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 1:4343 18TH AVE
Mailing Address - Street 2:
Mailing Address - City:ROCK ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:61201-3907
Mailing Address - Country:US
Mailing Address - Phone:309-786-9900
Mailing Address - Fax:309-786-9925
Practice Address - Street 1:4343 18TH AVE
Practice Address - Street 2:
Practice Address - City:ROCK ISLAND
Practice Address - State:IL
Practice Address - Zip Code:61201-3907
Practice Address - Country:US
Practice Address - Phone:309-786-9900
Practice Address - Fax:309-786-9925
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA06524111N00000X
PADC-006130-L111N00000X
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL08120282OtherBCBS
IL376760Medicare ID - Type Unspecified
IL08120282OtherBCBS