Healthcare Provider Details

I. General information

NPI: 1265502702
Provider Name (Legal Business Name): RANDALL L FISH DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2025 SE JEFFERSON ST
MILWAUKIE OR
97222
US

IV. Provider business mailing address

2025 SE JEFFERSON ST
MILWAUKIE OR
97222
US

V. Phone/Fax

Practice location:
  • Phone: 503-654-5433
  • Fax: 503-654-5439
Mailing address:
  • Phone: 503-654-5433
  • Fax: 503-654-5439

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number273520
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: