Provider Demographics
NPI:1679641591
Name:PRIDGEN, RANDALL EDWARD (LAT, ATC)
Entity type:Individual
Prefix:
First Name:RANDALL
Middle Name:EDWARD
Last Name:PRIDGEN
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2102 CAMERON RD SW
Mailing Address - Street 2:
Mailing Address - City:WILSON
Mailing Address - State:NC
Mailing Address - Zip Code:27893-4502
Mailing Address - Country:US
Mailing Address - Phone:252-289-5005
Mailing Address - Fax:252-399-6516
Practice Address - Street 1:501 ROUNTREE ST W
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27893-2811
Practice Address - Country:US
Practice Address - Phone:252-399-6520
Practice Address - Fax:252-399-6516
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC03282255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer