Provider Demographics
NPI:1609649169
Name:SMITH, RANDALL L (HIS)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:L
Last Name:SMITH
Suffix:
Gender:M
Credentials:HIS
Other - Prefix:
Other - First Name:RANDY
Other - Middle Name:L
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:HIS
Mailing Address - Street 1:6700 WASHINGTON AVE S
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-3405
Mailing Address - Country:US
Mailing Address - Phone:800-328-8602
Mailing Address - Fax:
Practice Address - Street 1:5120 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57108-5013
Practice Address - Country:US
Practice Address - Phone:605-221-0270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-06
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD320-H237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist