Provider Demographics
NPI:1588740674
Name:DAVIS, RANDOLPH CLARK (DC)
Entity type:Individual
Prefix:
First Name:RANDOLPH
Middle Name:CLARK
Last Name:DAVIS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:320 BAWDEN ST
Mailing Address - Street 2:SUITE 306
Mailing Address - City:KETCHIKAN
Mailing Address - State:AK
Mailing Address - Zip Code:99901-6503
Mailing Address - Country:US
Mailing Address - Phone:907-225-6815
Mailing Address - Fax:907-225-5767
Practice Address - Street 1:320 BAWDEN ST
Practice Address - Street 2:SUITE 306
Practice Address - City:KETCHIKAN
Practice Address - State:AK
Practice Address - Zip Code:99901-6503
Practice Address - Country:US
Practice Address - Phone:907-225-6815
Practice Address - Fax:907-225-5767
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-31
Last Update Date:2017-09-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AK149111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKK000QGCTNMedicare PIN