Provider Demographics
NPI:1568125854
Name:KEENER, RANDALL SCOTT (RDN)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:SCOTT
Last Name:KEENER
Suffix:
Gender:M
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7715 HICKORYWOOD DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-6619
Mailing Address - Country:US
Mailing Address - Phone:406-640-9976
Mailing Address - Fax:
Practice Address - Street 1:7715 HICKORYWOOD DR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-6619
Practice Address - Country:US
Practice Address - Phone:406-640-9976
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-14
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO989269133V00000X
989269133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO171449166Medicaid