Provider Demographics
NPI:1497332084
Name:COLEMAN, RANDY
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:
Last Name:COLEMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52303 CARRIAGE HILLS DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46635-1011
Mailing Address - Country:US
Mailing Address - Phone:574-272-1160
Mailing Address - Fax:
Practice Address - Street 1:52303 CARRIAGE HILLS DR
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46635-1011
Practice Address - Country:US
Practice Address - Phone:574-272-1160
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-28
Last Update Date:2021-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06004768A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty