Provider Demographics
NPI:1598716045
Name:RANDALL, JEFFREY (PT)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:RANDALL
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5718
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59903-5718
Mailing Address - Country:US
Mailing Address - Phone:406-756-0134
Mailing Address - Fax:406-300-1612
Practice Address - Street 1:9088 RIDGELINE BLVD STE 106
Practice Address - Street 2:
Practice Address - City:HIGHLANDS RANCH
Practice Address - State:CO
Practice Address - Zip Code:80129-2380
Practice Address - Country:US
Practice Address - Phone:720-458-0522
Practice Address - Fax:720-536-5365
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2020-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTL0007763225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC471318Medicare PIN