Provider Demographics
NPI:1679581169
Name:LERAAEN, RANDALL KEITH (DC)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:KEITH
Last Name:LERAAEN
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 1:754 S VAL VISTA DR STE 105
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85296-3139
Mailing Address - Country:US
Mailing Address - Phone:623-444-7100
Mailing Address - Fax:
Practice Address - Street 1:13733 N PRASADA PKWY STE 100
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85388-8014
Practice Address - Country:US
Practice Address - Phone:623-444-7100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5735111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ72773Medicare UPIN