Provider Demographics
NPI:1447357355
Name:SHORT, J RANDALL (DC)
Entity type:Individual
Prefix:DR
First Name:J
Middle Name:RANDALL
Last Name:SHORT
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
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Mailing Address - Street 1:30 CROSSING LANE
Mailing Address - Street 2:SUITE 207
Mailing Address - City:LEXINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:24450-6354
Mailing Address - Country:US
Mailing Address - Phone:540-464-5800
Mailing Address - Fax:540-464-5801
Practice Address - Street 1:30 CROSSING LANE
Practice Address - Street 2:SUITE 207
Practice Address - City:LEXINGTON
Practice Address - State:VA
Practice Address - Zip Code:24450-6354
Practice Address - Country:US
Practice Address - Phone:540-464-5800
Practice Address - Fax:540-464-5801
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0104000441111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA063073OtherANTHEM BCBS
VA063073OtherANTHEM BCBS