1417570532 NPI number — COREY HALL, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417570532 NPI number — COREY HALL, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COREY HALL, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
OUTLAST HEALTH AND PERFORMANCE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417570532
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/30/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1636 ABERDEEN RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TOWSON
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21286-8124
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
443-564-6085
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1600 W 41ST ST STE 300
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21211-1504
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-357-1529
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/22/2020

Additional Information

Authorized Official

Authorized Official Last Name:
HALL
Authorized Official First Name:
COREY
Authorized Official Middle Name:
ANDREW
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
443-564-6085

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2024 www.npivalidator.com