Provider Demographics
NPI:1689619496
Name:HAZELRIGG, GARY L (ATC)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:L
Last Name:HAZELRIGG
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2817 LOVERS LN
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64506-1523
Mailing Address - Country:US
Mailing Address - Phone:816-364-5803
Mailing Address - Fax:816-279-7574
Practice Address - Street 1:802 N RIVERSIDE RD
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64507-9794
Practice Address - Country:US
Practice Address - Phone:816-271-4953
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO000322255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer