Healthcare Provider Details

I. General information

NPI: 1770718587
Provider Name (Legal Business Name): QUINCY G. HALL IDMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2009
Last Update Date: 05/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

EGLIN AIR FORCE BASE 728TH ACS
APO AP
32542
US

IV. Provider business mailing address

772 SHADT ST.
FORT WALTON BEACH FL
32547
US

V. Phone/Fax

Practice location:
  • Phone: 250-883-1221
  • Fax:
Mailing address:
  • Phone: 850-883-1221
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1003X
TaxonomyIndependent Duty Medical Technicians
License Number1710I1003X
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: