1477381010 NPI number — MRS. MCKENZIE MARIE RANDALL DPT, PT, ATC

Table of content: MRS. MCKENZIE MARIE RANDALL DPT, PT, ATC (NPI 1477381010)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477381010 NPI number — MRS. MCKENZIE MARIE RANDALL DPT, PT, ATC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RANDALL
Provider First Name:
MCKENZIE
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
DPT, PT, ATC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DVORACEK
Provider Other First Name:
KENZIE
Provider Other Middle Name:
M
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1477381010
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/24/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
34358 254TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHAMBERLAIN
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57325-6320
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-464-1466
Provider Business Mailing Address Fax Number:
605-234-0164

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 PAUL GUST RD STE 109
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHAMBERLAIN
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57325-1021
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-234-0165
Provider Business Practice Location Address Fax Number:
605-234-0164
Provider Enumeration Date:
07/24/2024

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208100000X , with the licence number:  1767 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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