Provider Demographics
NPI:1881818391
Name:SHIDELER, RANDY JAMES (DC)
Entity Type:Individual
Prefix:DR
First Name:RANDY
Middle Name:JAMES
Last Name:SHIDELER
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 1:753 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BLUFFTON
Mailing Address - State:IN
Mailing Address - Zip Code:46714-1313
Mailing Address - Country:US
Mailing Address - Phone:260-824-0318
Mailing Address - Fax:
Practice Address - Street 1:753 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BLUFFTON
Practice Address - State:IN
Practice Address - Zip Code:46714-1313
Practice Address - Country:US
Practice Address - Phone:260-824-0318
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08000719A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN058890Medicare ID - Type Unspecified