Provider Demographics
NPI:1790813517
Name:CARMICHAEL, RANDY L (DC)
Entity Type:Individual
Prefix:DR
First Name:RANDY
Middle Name:L
Last Name:CARMICHAEL
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 1:3937 W ROLL AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-3181
Mailing Address - Country:US
Mailing Address - Phone:812-332-3232
Mailing Address - Fax:812-332-3273
Practice Address - Street 1:3937 W ROLL AVE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-3181
Practice Address - Country:US
Practice Address - Phone:812-332-3232
Practice Address - Fax:812-332-3273
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2011-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08000787A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
INCA54351Medicaid
INCA54351Medicaid