Healthcare Provider Details

I. General information

NPI: 1205242575
Provider Name (Legal Business Name): KELLY JO HALL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2014
Last Update Date: 07/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

98 W STATE ST
MILFORD CENTER OH
43045-9008
US

IV. Provider business mailing address

98 W STATE ST
MILFORD CENTER OH
43045-9008
US

V. Phone/Fax

Practice location:
  • Phone: 937-707-7263
  • Fax:
Mailing address:
  • Phone: 937-707-7263
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License NumberRG498703
License Number StateOH

VIII. Authorized Official

Name: KELLY JO HALL
Title or Position: MEMBER
Credential:
Phone: 937-707-7263