Healthcare Provider Details

I. General information

NPI: 1831112697
Provider Name (Legal Business Name): MR. RANDY WAYNE ROSE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 09/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1505 MAIN ST
HILTON HEAD SC
29926
US

IV. Provider business mailing address

1505 MAIN ST
HILTON HEAD SC
29926-1608
US

V. Phone/Fax

Practice location:
  • Phone: 843-547-5832
  • Fax:
Mailing address:
  • Phone: 843-547-5832
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number0640
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License NumberHA2772
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: