=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235112103
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RANDALL RAYMOND BEACH D.C.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/23/2005
-----------------------------------------------------
Last Update Date | 07/09/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 300 W 23RD ST BEACH CHIROPRACTIC ARTS CENTER
-----------------------------------------------------
City | FREMONT
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68025-2547
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-721-1190
-----------------------------------------------------
Fax | 402-721-1199
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 300 W 23RD ST
-----------------------------------------------------
City | FREMONT
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68025-2547
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-721-1190
-----------------------------------------------------
Fax | 402-721-1199
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 690
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------