Provider Demographics
NPI:1659543205
Name:RANDOM LAKE SPINE & SPORTS CLINIC
Entity Type:Organization
Organization Name:RANDOM LAKE SPINE & SPORTS CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:C
Authorized Official - Last Name:RUDELICH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:920-994-2000
Mailing Address - Street 1:PO BOX 196
Mailing Address - Street 2:
Mailing Address - City:RANDOM LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:53075-0196
Mailing Address - Country:US
Mailing Address - Phone:920-994-2000
Mailing Address - Fax:
Practice Address - Street 1:321 CARROLL ST.
Practice Address - Street 2:
Practice Address - City:RANDOM LAKE
Practice Address - State:WI
Practice Address - Zip Code:53075
Practice Address - Country:US
Practice Address - Phone:920-994-2000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-24
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center