Healthcare Provider Details

I. General information

NPI: 1508322736
Provider Name (Legal Business Name): CHRISTOPHER SHANE HALL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/12/2019
Last Update Date: 02/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

916 E REZANOF DR
KODIAK AK
99615-6724
US

IV. Provider business mailing address

PO BOX 147
KODIAK AK
99615-0147
US

V. Phone/Fax

Practice location:
  • Phone: 907-486-3995
  • Fax:
Mailing address:
  • Phone: 907-942-1294
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: