NPIMap

Organization Active NPI

Random Lake Spine & Sports Clinic

  • Clinic/Center
  • Random Lake, WI
National Provider Identifier
1659543205
Registry record updated Jun 2, 2008
On this page

Key facts

NPPES NPI Registry
Primary specialty
Clinic/CenterTaxonomy code 261Q00000X
Legal business name
RANDOM LAKE SPINE & SPORTS CLINIC
Practice address
321 Carroll St.
Random Lake, WI 53075
Phone
(920) 994-2000
NPI assigned
Mar 24, 2008
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 2, 2008

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Jason C Rudelich, D.C.
Title
President
Phone
(920) 994-2000

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Clinic/Center 261Q00000X Primary

Addresses

Primary practice location

321 Carroll St.
Random Lake, WI 53075

Mailing address

PO Box 196
Random Lake, WI 53075-0196
Phone (920) 994-2000

National Provider Directory

National Provider Directory

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1206316800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1212364800000",
    "number": "1659543205",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 196",
            "city": "RANDOM LAKE",
            "state": "WI",
            "postal_code": "530750196",
            "telephone_number": "920-994-2000"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "321 CARROLL ST.",
            "city": "RANDOM LAKE",
            "state": "WI",
            "postal_code": "53075",
            "telephone_number": "920-994-2000"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "RANDOM LAKE SPINE & SPORTS CLINIC",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-03-24",
        "last_updated": "2008-06-02",
        "status": "A",
        "authorized_official_last_name": "RUDELICH",
        "authorized_official_first_name": "JASON",
        "authorized_official_middle_name": "C",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "920-994-2000",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "D.C."
    },
    "taxonomies": [
        {
            "code": "261Q00000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Random Lake, WI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 2, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.