Provider Demographics
NPI:1194317065
Name:HALL, RYAN RANDLE
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:RANDLE
Last Name:HALL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 CRISTIANITOS RD UNIT 14205
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92673-6983
Mailing Address - Country:US
Mailing Address - Phone:303-903-6701
Mailing Address - Fax:
Practice Address - Street 1:1025 ATLANTIC AVE STE 101
Practice Address - Street 2:
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94501-1188
Practice Address - Country:US
Practice Address - Phone:510-268-8120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-10
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician