Healthcare Provider Details

I. General information

NPI: 1215947932
Provider Name (Legal Business Name): RANDALL J. MCCLELLAN O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 06/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14406 NE 20TH AVE
VANCOUVER WA
98686-1448
US

IV. Provider business mailing address

14406 NE 20TH AVE
VANCOUVER WA
98686-1448
US

V. Phone/Fax

Practice location:
  • Phone: 360-571-3084
  • Fax: 360-571-3082
Mailing address:
  • Phone: 360-571-3084
  • Fax: 360-571-3082

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3180AT
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number3180AT
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: