Provider Demographics
NPI:1609499185
Name:HACKNEY, GARY LEROY
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:LEROY
Last Name:HACKNEY
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 1:310 ROUTE 66 E
Mailing Address - Street 2:
Mailing Address - City:WAYNESVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:65583-2648
Mailing Address - Country:US
Mailing Address - Phone:573-855-1213
Mailing Address - Fax:
Practice Address - Street 1:310 ROUTE 66 E
Practice Address - Street 2:
Practice Address - City:WAYNESVILLE
Practice Address - State:MO
Practice Address - Zip Code:65583-2648
Practice Address - Country:US
Practice Address - Phone:573-855-1213
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-19
Last Update Date:2020-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012024227225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty