Healthcare Provider Details

I. General information

NPI: 1184176273
Provider Name (Legal Business Name): DAVID HALL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2016
Last Update Date: 10/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

167 POLK ST SUITE 300
WATERTOWN NY
13601-2097
US

IV. Provider business mailing address

PO BOX 6550
WATERTOWN NY
13601-6550
US

V. Phone/Fax

Practice location:
  • Phone: 315-782-7445
  • Fax: 315-779-1184
Mailing address:
  • Phone: 315-788-7430
  • Fax: 315-785-5637

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number098349
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: