Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111N00000X | Chiropractor | 893 | AR |
NPI | 1003804576 |
---|---|
Provider Name | Dr. Randall Gregg Davis |
First Address | Russellville, AR 72801-2936 |
Second Address | Russellville, AR 72801-2936 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/10/2005 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
T20577 | (02) |