Healthcare Provider Details

I. General information

NPI: 1891338133
Provider Name (Legal Business Name): SAMUEL MATTHEWS HALE CPO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2019
Last Update Date: 10/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2710 AMNICOLA HWY
CHATTANOOGA TN
37406-3603
US

IV. Provider business mailing address

712 MORNING SHADOWS DR
CHATTANOOGA TN
37421-2055
US

V. Phone/Fax

Practice location:
  • Phone: 423-624-0946
  • Fax:
Mailing address:
  • Phone: 423-605-8222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code222Z00000X
TaxonomyOrthotist
License Number221
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number120
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number200
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: