Healthcare Provider Details

I. General information

NPI: 1356771539
Provider Name (Legal Business Name): RANDY FORE HIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/25/2013
Last Update Date: 11/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 N COLLEGE ST
MOUNTAIN HOME AR
72653-3654
US

IV. Provider business mailing address

202 N COLLEGE ST
MOUNTAIN HOME AR
72653-3654
US

V. Phone/Fax

Practice location:
  • Phone: 870-424-4600
  • Fax: 870-424-6950
Mailing address:
  • Phone: 870-424-4600
  • Fax: 870-424-6950

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number588
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: