Healthcare Provider Details

I. General information

NPI: 1467182550
Provider Name (Legal Business Name): RANDY HALE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2022
Last Update Date: 06/13/2022
Certification Date: 06/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4429 S RIVER BLVD STE BC
INDEPENDENCE MO
64055-4659
US

IV. Provider business mailing address

4429 S RIVER BLVD STE BC
INDEPENDENCE MO
64055-4659
US

V. Phone/Fax

Practice location:
  • Phone: 816-768-0090
  • Fax: 816-912-1739
Mailing address:
  • Phone: 816-768-0090
  • Fax: 816-912-1739

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: