Provider Demographics
NPI:1982787891
Name:LEAVITT, RANDALL HUGH (DC)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:HUGH
Last Name:LEAVITT
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 1:844 N EMERSON ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97217-2533
Mailing Address - Country:US
Mailing Address - Phone:503-280-2082
Mailing Address - Fax:
Practice Address - Street 1:1706 NW GLISAN ST
Practice Address - Street 2:SUITE 5
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-2225
Practice Address - Country:US
Practice Address - Phone:503-228-5000
Practice Address - Fax:503-228-5019
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR273413111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor