Provider Demographics
NPI:1285739672
Name:BAACK, RANDALL SCOTT (ATC)
Entity type:Individual
Prefix:
First Name:RANDALL
Middle Name:SCOTT
Last Name:BAACK
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:SEWARD
Mailing Address - State:NE
Mailing Address - Zip Code:68434-1533
Mailing Address - Country:US
Mailing Address - Phone:402-643-6863
Mailing Address - Fax:
Practice Address - Street 1:800 N COLUMBIA AVE
Practice Address - Street 2:
Practice Address - City:SEWARD
Practice Address - State:NE
Practice Address - Zip Code:68434-1556
Practice Address - Country:US
Practice Address - Phone:402-643-7420
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE3662255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer