Provider Demographics
NPI:1659419331
Name:KLINEDINST, RANDY LAVERNE (DC)
Entity Type:Individual
Prefix:DR
First Name:RANDY
Middle Name:LAVERNE
Last Name:KLINEDINST
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 1:106 MARTIN AVE
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:IL
Mailing Address - Zip Code:61520-2519
Mailing Address - Country:US
Mailing Address - Phone:309-647-8030
Mailing Address - Fax:309-647-5902
Practice Address - Street 1:106 MARTIN AVE
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:IL
Practice Address - Zip Code:61520-2519
Practice Address - Country:US
Practice Address - Phone:309-647-8030
Practice Address - Fax:309-647-5902
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2015-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-004195111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL2982004OtherBLUE CROSS BLUE SHIELD
ILT37604Medicare UPIN
IL662780Medicare PIN