Provider Demographics
NPI:1952469967
Name:RANDALL, JEFFREY BLAINE (DC)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:BLAINE
Last Name:RANDALL
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 1:434 S KIWANIS AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57104-3710
Mailing Address - Country:US
Mailing Address - Phone:605-332-7706
Mailing Address - Fax:605-332-2430
Practice Address - Street 1:434 S KIWANIS AVE
Practice Address - Street 2:SUITE A
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57104-3710
Practice Address - Country:US
Practice Address - Phone:605-332-7706
Practice Address - Fax:605-332-2430
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1099111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN29C03RAOtherBC/BS
SD0004329OtherBC/BS
SD7603990Medicaid
SDU59943Medicare UPIN
MN29C03RAOtherBC/BS