Healthcare Provider Details

I. General information

NPI: 1265582795
Provider Name (Legal Business Name): TERESA A HALL RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8777 BROADWAY
MERRILLVILLE IN
46410-7035
US

IV. Provider business mailing address

PO BOX 906
SCHERERVILLE IN
46375-0906
US

V. Phone/Fax

Practice location:
  • Phone: 219-712-6253
  • Fax:
Mailing address:
  • Phone: 219-712-6253
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number164003616
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: