=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952065328
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HALLMEDICAL CLINIC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/22/2021
-----------------------------------------------------
Last Update Date | 10/22/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 107 JV MANGUBAT DR
-----------------------------------------------------
City | WAYNESBORO
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38485-2440
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 931-722-2800
-----------------------------------------------------
Fax | 931-722-9627
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 689
-----------------------------------------------------
City | WAYNESBORO
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38485-0689
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 931-722-2800
-----------------------------------------------------
Fax | 931-722-9627
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | VALERIE A HALL-GLASS
-----------------------------------------------------
Credential | APN
-----------------------------------------------------
Telephone | 931-722-2800
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------