MEDICARE: DR. RANDAL JOSEPH JACKLITCH 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	2434	MN

General Provider Information

NPI Number	:	1447201561
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RANDAL JOSEPH JACKLITCH D.C.

Provider Business Mailing Address
First Line	:	208 W JAMES ST
Second Line	:	P.O. BOX 79
City	:	PAYNESVILLE
State	:	MN
Zip	:	56362-1219
Country	:	US
Telephone Number	:	320-243-7412
Fax Number	:	320-243-7170

Provider Business Practice Location Address
First Line	:	645 LAKE AVE S
Second Line	:
City	:	PAYNESVILLE
State	:	MN
Zip	:	56362-1736
Country	:	US
Telephone Number	:	320-243-7412
Fax Number	:	320-243-7170

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

Provider Enumeration Date	:	05/13/2006
Last Update Date	:	08/31/2016

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