Healthcare Provider Details

I. General information

NPI: 1982870234
Provider Name (Legal Business Name): CORRINE CARPENTER LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/07/2008
Last Update Date: 05/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 N WALNUT
BLOOMINGTON IN
47404
US

IV. Provider business mailing address

2401 N WALNUT
BLOOMINGTON IN
47404
US

V. Phone/Fax

Practice location:
  • Phone: 812-323-0095
  • Fax: 812-333-0961
Mailing address:
  • Phone: 812-323-0095
  • Fax: 812-333-0961

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number84000030A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: