MEDICARE: THERESSA HALL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1619381084
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THERESSA HALL

Provider Business Mailing Address
First Line	:	2401 NW 122ND ST
Second Line	:	APT 71
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73120-8493
Country	:	US
Telephone Number	:	405-209-2398
Fax Number	:

Provider Business Practice Location Address
First Line	:	1330 N. CLASSEN BLVD
Second Line	:	SUITE 302
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73106
Country	:	US
Telephone Number	:	405-555-5555
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/13/2014
Last Update Date	:	06/13/2014

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