Healthcare Provider Details

I. General information

NPI: 1336228345
Provider Name (Legal Business Name): CLINTON RANDALL THOMAS DIP. AC., L.AC.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9900 SW WILSHIRE 190-C
PORTLAND OR
97225
US

IV. Provider business mailing address

12471 SE LINWOOD AVE E4
MILWAUKIE OR
97222-2439
US

V. Phone/Fax

Practice location:
  • Phone: 503-297-3825
  • Fax: 503-297-3827
Mailing address:
  • Phone: 503-659-1141
  • Fax: 503-297-3827

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC00512
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: