Healthcare Provider Details

I. General information

NPI: 1457327363
Provider Name (Legal Business Name): JEREMIAH HALES M.S.,L.P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/28/2006
Last Update Date: 10/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5107 W 98TH ST
BLOOMINGTON MN
55437-2040
US

IV. Provider business mailing address

5107 W 98TH ST
BLOOMINGTON MN
55437-2040
US

V. Phone/Fax

Practice location:
  • Phone: 612-226-5729
  • Fax:
Mailing address:
  • Phone: 612-226-5729
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number6782
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: