MEDICARE: MR. RANDALL RAYMOND BEACH D.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	690	NE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	09811	OTHER	NE	BLUE CROSS BLUE SHIELD
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1235112103
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RANDALL RAYMOND BEACH D.C.

Provider Business Mailing Address
First Line	:	300 W 23RD ST
Second Line	:
City	:	FREMONT
State	:	NE
Zip	:	68025-2547
Country	:	US
Telephone Number	:	402-721-1190
Fax Number	:	402-721-1199

Provider Business Practice Location Address
First Line	:	300 W 23RD ST
Second Line	:	BEACH CHIROPRACTIC ARTS CENTER
City	:	FREMONT
State	:	NE
Zip	:	68025-2547
Country	:	US
Telephone Number	:	402-721-1190
Fax Number	:	402-721-1199

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/23/2005
Last Update Date	:	07/09/2007

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