Basic Information
| Provider Information | |||||||||
| NPI: | 1164452751 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BARR | ||||||||
| FirstName: | RANDALL | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | DPT, MS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6550 SE 143RD CT | ||||||||
| Address2: | |||||||||
| City: | MORRISTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326684589 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6628017564 | ||||||||
| FaxNumber: | 8552328604 | ||||||||
| Practice Location | |||||||||
| Address1: | 6550 SE 143RD CT | ||||||||
| Address2: | |||||||||
| City: | MORRISTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326684589 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6628017564 | ||||||||
| FaxNumber: | 8552328604 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2006 | ||||||||
| LastUpdateDate: | 06/21/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT3539 | MS | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | PT34432 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 07522770 | 05 | MS | MEDICAID |