Provider Demographics
NPI:1083894034
Name:THE SPARK OF LIFE INC.
Entity Type:Organization
Organization Name:THE SPARK OF LIFE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:L
Authorized Official - Last Name:FISH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:503-595-1717
Mailing Address - Street 1:9900 SW WILSHIRE ST
Mailing Address - Street 2:STE 170
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-5035
Mailing Address - Country:US
Mailing Address - Phone:503-595-1717
Mailing Address - Fax:503-595-1719
Practice Address - Street 1:9900 SW WILSHIRE ST
Practice Address - Street 2:STE 170
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-5035
Practice Address - Country:US
Practice Address - Phone:503-595-1717
Practice Address - Fax:503-595-1719
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-07
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR273520111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR133897Medicare PIN