Provider Demographics
NPI:1578665139
Name:ROEHL, RANDALL LEROY (DC)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:LEROY
Last Name:ROEHL
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 1:14600 10TH AVE S
Mailing Address - Street 2:SUITE 600
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337-4643
Mailing Address - Country:US
Mailing Address - Phone:952-432-3777
Mailing Address - Fax:
Practice Address - Street 1:14600 10TH AVE S
Practice Address - Street 2:SUITE 600
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-4643
Practice Address - Country:US
Practice Address - Phone:952-432-3777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2259111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
743156824OtherEIN