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General NPI Number Information
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NPI Number | 1679581169
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Entity Type | Individual
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Provider Name | RANDALL KEITH LERAAEN D.C.
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Gender | Male
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Dates
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Enumeration Date | 08/03/2006
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Last Update Date | 10/23/2023
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Provider Practice Location Address
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Address Line | 13733 N PRASADA PKWY STE 100
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City | SURPRISE
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State | AZ
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Zip | 85388-8014
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Country | US
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Telephone | 623-444-7100
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Fax |
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Provider Business Mailing Address
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Address Line | 754 S VAL VISTA DR STE 105
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City | GILBERT
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State | AZ
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Zip | 85296-3139
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Country | US
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Telephone | 623-444-7100
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 5735
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License Number State | AZ
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