Provider Demographics
NPI:1578730677
Name:HALL, BAYETE CHANGAMIRE SR (CMT)
Entity Type:Individual
Prefix:
First Name:BAYETE
Middle Name:CHANGAMIRE
Last Name:HALL
Suffix:SR
Gender:M
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1961 RICE ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-6828
Mailing Address - Country:US
Mailing Address - Phone:651-329-4753
Mailing Address - Fax:
Practice Address - Street 1:1961 RICE ST
Practice Address - Street 2:SUITE 202
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-6828
Practice Address - Country:US
Practice Address - Phone:651-329-4753
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-08
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2008291173C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173C00000XOther Service ProvidersReflexologist