Healthcare Provider Details

I. General information

NPI: 1578531992
Provider Name (Legal Business Name): L.V. HALL JR. IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

USS SAMUEL B. ROBERTS (FFG 58) FPO AA
MAYPORT FL
34092-1512
US

IV. Provider business mailing address

USS SAMUEL B. ROBERTS (FFG 58) FPO AA
MAYPORT FL
34092-1512
US

V. Phone/Fax

Practice location:
  • Phone: 904-270-6230
  • Fax:
Mailing address:
  • Phone: 904-270-6230
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: