Provider Demographics
NPI:1710161021
Name:THE SPARK OF LIFE CHIROPRACTIC & WELLNESS
Entity Type:Organization
Organization Name:THE SPARK OF LIFE CHIROPRACTIC & WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
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:503-654-5433
Mailing Address - Street 1:2025 SE JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222-7605
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:97222-7605
Practice Address - Country:US
Practice Address - Phone:503-654-5433
Practice Address - Fax:503-654-5439
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-21
Last Update Date:2007-12-21
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