Provider Demographics
NPI:1124009105
Name:DIERENFIELD, RANDY RALPH (DC)
Entity Type:Individual
Prefix:DR
First Name:RANDY
Middle Name:RALPH
Last Name:DIERENFIELD
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 1:110 NE TRILEIN DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:ANKENY
Mailing Address - State:IA
Mailing Address - Zip Code:50021-2041
Mailing Address - Country:US
Mailing Address - Phone:515-965-1810
Mailing Address - Fax:
Practice Address - Street 1:110 NE TRILEIN DR
Practice Address - Street 2:SUITE 1
Practice Address - City:ANKENY
Practice Address - State:IA
Practice Address - Zip Code:50021-2041
Practice Address - Country:US
Practice Address - Phone:515-965-1810
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA04762111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA20429Medicare ID - Type Unspecified