Basic Information
| Provider Information | |||||||||
| NPI: | 1669879730 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CAPELLE | ||||||||
| FirstName: | RANDY | ||||||||
| MiddleName: | THOMAS | ||||||||
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| Credential: | MPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 CROSS ST | ||||||||
| Address2: | |||||||||
| City: | BIG STONE CITY | ||||||||
| State: | SD | ||||||||
| PostalCode: | 572168237 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6055411140 | ||||||||
| FaxNumber: | 6055410109 | ||||||||
| Practice Location | |||||||||
| Address1: | 15620 EDGEWOOD DR STE 240 | ||||||||
| Address2: | |||||||||
| City: | BAXTER | ||||||||
| State: | MN | ||||||||
| PostalCode: | 564016984 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2184547012 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/04/2014 | ||||||||
| LastUpdateDate: | 03/07/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 6725 | MN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 6725 | 01 | MN | MN BOARD OF PHYSICAL THERAPY | OTHER |