Provider Demographics
NPI:1760564926
Name:NODORFT, RANDALL W (DC)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:W
Last Name:NODORFT
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 1:1920 TOWN HALL RD
Mailing Address - Street 2:
Mailing Address - City:BELOIT
Mailing Address - State:WI
Mailing Address - Zip Code:53511-9770
Mailing Address - Country:US
Mailing Address - Phone:608-362-7693
Mailing Address - Fax:
Practice Address - Street 1:884 S JANESVILLE ST
Practice Address - Street 2:SUITE C
Practice Address - City:WHITEWATER
Practice Address - State:WI
Practice Address - Zip Code:53190-2508
Practice Address - Country:US
Practice Address - Phone:262-472-9115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4057111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI743131825015OtherBCBS
WIV02858Medicare UPIN