Healthcare Provider Details

I. General information

NPI: 1992932552
Provider Name (Legal Business Name): CHAD DERICK HALL PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2009
Last Update Date: 09/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26396 BAY FARM RD BACK BAY PARK CENTER
LONG NECK DE
19966-4993
US

IV. Provider business mailing address

2 W 10TH ST
MARCUS HOOK PA
19061-4513
US

V. Phone/Fax

Practice location:
  • Phone: 302-947-9662
  • Fax: 302-947-9692
Mailing address:
  • Phone: 610-859-8850
  • Fax: 610-859-7876

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License NumberJ2-0000674
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: