Basic Information
| Provider Information | |||||||||
| NPI: | 1588939060 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SIMMONS | ||||||||
| FirstName: | RANDOL | ||||||||
| MiddleName: | BROCK | ||||||||
| NamePrefix: | |||||||||
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| Credential: | D.P.T. | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2311 LAKE PARK DR | ||||||||
| Address2: | |||||||||
| City: | ALBANY | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317073183 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2294350525 | ||||||||
| FaxNumber: | 2294349827 | ||||||||
| Practice Location | |||||||||
| Address1: | 2311 LAKE PARK DR | ||||||||
| Address2: | |||||||||
| City: | ALBANY | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317073183 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2294350525 | ||||||||
| FaxNumber: | 2294349827 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2012 | ||||||||
| LastUpdateDate: | 03/15/2012 | ||||||||
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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 | 174400000X | PT009819 | GA | Y | Other Service Providers | Specialist |
No ID Information.