1568693166 NPI number — CHRISTINE DEBRA HALL OTR

Table of content: CHRISTINE DEBRA HALL OTR (NPI 1568693166)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568693166 NPI number — CHRISTINE DEBRA HALL OTR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HALL
Provider First Name:
CHRISTINE
Provider Middle Name:
DEBRA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OTR
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LARSEN
Provider Other First Name:
CHRISTINE
Provider Other Middle Name:
DEBRA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
OTR
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1568693166
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/16/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15861 FLUTE WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
APPLE VALLEY
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55124-6011
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-953-9568
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8320 CITY CENTRE DR
Provider Second Line Business Practice Location Address:
SUITE G.
Provider Business Practice Location Address City Name:
WOODBURY
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55125-3382
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-738-9888
Provider Business Practice Location Address Fax Number:
651-738-9889
Provider Enumeration Date:
07/30/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225X00000X , with the licence number:  255808 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 255808 . This is a "LICENSE NUMBER" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".