Healthcare Provider Details

I. General information

NPI: 1396015996
Provider Name (Legal Business Name): CHRIS DOUGLAS HALL ATC, MED
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/12/2012
Last Update Date: 01/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1950 45TH AVE
MUNSTER IN
46321-3927
US

IV. Provider business mailing address

2101 SHERWOOD LAKE DRIVE APT. 3A
SCHERERVILLE IN
46375-2724
US

V. Phone/Fax

Practice location:
  • Phone: 219-922-8188
  • Fax:
Mailing address:
  • Phone: 219-576-4599
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number36001167A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: