Provider Demographics
NPI:1730246844
Name:SMITH, RANDALL WARREN (DC)
Entity type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:WARREN
Last Name:SMITH
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 1:442 SUNNYSIDE AVE.
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60187
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:442 SUNNYSIDE AVE.
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60187-5006
Practice Address - Country:US
Practice Address - Phone:630-517-8670
Practice Address - Fax:630-517-8671
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2012-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038005471111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
747250Medicare ID - Type Unspecified
I38456Medicare UPIN