Provider Demographics
NPI:1336371699
Name:DRAKE, RANDALL GALEN (DC)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:GALEN
Last Name:DRAKE
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 1:15 BAY HILL CT
Mailing Address - Street 2:
Mailing Address - City:LAKE OZARK
Mailing Address - State:MO
Mailing Address - Zip Code:65049-9097
Mailing Address - Country:US
Mailing Address - Phone:573-286-4412
Mailing Address - Fax:
Practice Address - Street 1:15 BAY HILL CT
Practice Address - Street 2:
Practice Address - City:LAKE OZARK
Practice Address - State:MO
Practice Address - Zip Code:65049-9097
Practice Address - Country:US
Practice Address - Phone:573-286-4412
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-19
Last Update Date:2014-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009021121111N00000X, 111N00000X
CA13767111N00000X
MI2301002872111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor