Healthcare Provider Details

I. General information

NPI: 1790018687
Provider Name (Legal Business Name): RANDAL F BALES BA/ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2009
Last Update Date: 09/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7622 MCLAUGHLIN RD
PEYTON CO
80831-4710
US

IV. Provider business mailing address

7622 MCLAUGHLIN RD
PEYTON CO
80831-4710
US

V. Phone/Fax

Practice location:
  • Phone: 719-495-3133
  • Fax: 719-495-8685
Mailing address:
  • Phone: 719-495-3133
  • Fax: 719-495-8685

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: