Provider Demographics
NPI:1477644375
Name:O'DELL, RANDOLPH CLAY (DC)
Entity Type:Individual
Prefix:DR
First Name:RANDOLPH
Middle Name:CLAY
Last Name:O'DELL
Suffix:
Gender:M
Credentials:DC
Other - Prefix:DR
Other - First Name:RANDOLPH
Other - Middle Name:C
Other - Last Name:O'DELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:1183 PONTIAC TRAIL
Mailing Address - Street 2:
Mailing Address - City:WALLED LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48390
Mailing Address - Country:US
Mailing Address - Phone:248-624-6111
Mailing Address - Fax:248-624-6129
Practice Address - Street 1:1183 PONTIAC TRAIL
Practice Address - Street 2:
Practice Address - City:WALLED LAKE
Practice Address - State:MI
Practice Address - Zip Code:48390
Practice Address - Country:US
Practice Address - Phone:248-624-6111
Practice Address - Fax:248-624-6129
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301002842111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1279839Medicaid
MI142073OtherAETNA INSURANCE
MIT33365Medicare UPIN
MI1279839Medicaid