Provider Demographics
NPI:1528369550
Name:MARTIN, RANDALL LEE (DC)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:LEE
Last Name:MARTIN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:59771 GARVER AVE
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46517-3727
Mailing Address - Country:US
Mailing Address - Phone:574-238-6609
Mailing Address - Fax:
Practice Address - Street 1:2400 ELKHART RD
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46526-1010
Practice Address - Country:US
Practice Address - Phone:574-534-2500
Practice Address - Fax:574-534-2500
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-08
Last Update Date:2013-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08002644A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor