=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851061956
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MR. LARRY D HALL JR.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/20/2021
-----------------------------------------------------
Last Update Date | 09/19/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3010 15TH AVE S
-----------------------------------------------------
City | GREAT FALLS
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59405-5240
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-216-8000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 435 WATERBURY CT
-----------------------------------------------------
City | CANTONMENT
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32533-8411
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-529-9135
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number | 240740
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 364SA2100X
-----------------------------------------------------
Taxonomy Name | Acute Care Clinical Nurse Specialist
-----------------------------------------------------
License Number | 11015472
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------