Healthcare Provider Details

I. General information

NPI: 1861482002
Provider Name (Legal Business Name): JACK LEROY HALING MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2005
Last Update Date: 03/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

824 PINE ST
MOUNT SHASTA CA
96067-2137
US

IV. Provider business mailing address

PO BOX 339
MOUNT SHASTA CA
96067-0339
US

V. Phone/Fax

Practice location:
  • Phone: 530-926-4528
  • Fax: 530-926-5070
Mailing address:
  • Phone: 530-926-5613
  • Fax: 530-926-8798

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberC28244
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: