Provider Demographics
NPI:1235112103
Name:BEACH, RANDALL RAYMOND (DC)
Entity Type:Individual
Prefix:MR
First Name:RANDALL
Middle Name:RAYMOND
Last Name:BEACH
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 1:300 W 23RD ST
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:NE
Mailing Address - Zip Code:68025-2547
Mailing Address - Country:US
Mailing Address - Phone:402-721-1190
Mailing Address - Fax:402-721-1199
Practice Address - Street 1:300 W 23RD ST
Practice Address - Street 2:BEACH CHIROPRACTIC ARTS CENTER
Practice Address - City:FREMONT
Practice Address - State:NE
Practice Address - Zip Code:68025-2547
Practice Address - Country:US
Practice Address - Phone:402-721-1190
Practice Address - Fax:402-721-1199
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE690111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE09811OtherBLUE CROSS BLUE SHIELD
NE47075074900Medicaid
NET40176Medicare UPIN
NE091493Medicare ID - Type UnspecifiedMEDICARE