Healthcare Provider Details

I. General information

NPI: 1770300188
Provider Name (Legal Business Name): CARSON SANDY DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2024
Last Update Date: 09/25/2024
Certification Date: 09/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 W BEECH ST
SULLIVAN IN
47882-1462
US

IV. Provider business mailing address

222 W BEECH ST
SULLIVAN IN
47882-1462
US

V. Phone/Fax

Practice location:
  • Phone: 812-268-3400
  • Fax: 812-268-5713
Mailing address:
  • Phone: 812-268-3400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number08003466A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: