Provider Demographics
NPI:1952471633
Name:LISH, RANDALL WAYNE (DC)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:WAYNE
Last Name:LISH
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 1:3315 BEMIDJI AVE N
Mailing Address - Street 2:
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56601-4330
Mailing Address - Country:US
Mailing Address - Phone:218-444-2225
Mailing Address - Fax:218-444-7225
Practice Address - Street 1:3315 BEMIDJI AVE N
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-4330
Practice Address - Country:US
Practice Address - Phone:218-444-2225
Practice Address - Fax:218-444-7225
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3170111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN78B72LIOtherBCBS