Provider Demographics
NPI:1265502702
Name:FISH, RANDALL L (DC)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:L
Last Name:FISH
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 1:2025 SE JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222
Mailing Address - Country:US
Mailing Address - Phone:503-654-5433
Mailing Address - Fax:503-654-5439
Practice Address - Street 1:2025 SE JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222
Practice Address - Country:US
Practice Address - Phone:503-654-5433
Practice Address - Fax:503-654-5439
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR273520111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
U91902Medicare UPIN
133897Medicare ID - Type UnspecifiedGROUP
133898Medicare ID - Type Unspecified