Provider Demographics
NPI:1114094182
Name:PEDERSON, RANDALL EDWARD (DC)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:EDWARD
Last Name:PEDERSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 MINNESOTA AVE E
Mailing Address - Street 2:
Mailing Address - City:GLENWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:56334-1627
Mailing Address - Country:US
Mailing Address - Phone:320-634-4737
Mailing Address - Fax:320-634-4737
Practice Address - Street 1:131 MINNESOTA AVE E
Practice Address - Street 2:
Practice Address - City:GLENWOOD
Practice Address - State:MN
Practice Address - Zip Code:56334-1627
Practice Address - Country:US
Practice Address - Phone:320-634-4737
Practice Address - Fax:320-634-4737
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1828111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1C090PEOtherBCBS IPN
MN49316PEOtherBCBS MPIN
MNT65976Medicare UPIN