Provider Demographics
NPI:1366440802
Name:CALICO, RANDALL M (PT)
Entity Type:Individual
Prefix:MR
First Name:RANDALL
Middle Name:M
Last Name:CALICO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:370 HIGHLAND PARK DR
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:KY
Mailing Address - Zip Code:40475-3546
Mailing Address - Country:US
Mailing Address - Phone:859-625-9700
Mailing Address - Fax:859-625-1555
Practice Address - Street 1:370 HIGHLAND PARK DR
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:KY
Practice Address - Zip Code:40475-3546
Practice Address - Country:US
Practice Address - Phone:859-625-9700
Practice Address - Fax:859-625-1555
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY004663225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000333695OtherBLUE CROSS
KY5020708Medicare ID - Type Unspecified