Basic Information
| Provider Information | |||||||||
| NPI: | 1609260413 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HALL | ||||||||
| FirstName: | MICHAEL | ||||||||
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| Credential: | ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 201 MCANDREWS RD W | ||||||||
| Address2: | APT 216 | ||||||||
| City: | BURNSVILLE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553375708 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 8100 W 78TH ST | ||||||||
| Address2: | SUITE #230 | ||||||||
| City: | EDINA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554392516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529469777 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2015 | ||||||||
| LastUpdateDate: | 07/07/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | 2663 | MN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.