Basic Information
| Provider Information | |||||||||
| NPI: | 1861743924 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HALLETT ENTERPRISES, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PT LINK | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 256 S GORDON DR | ||||||||
| Address2: | |||||||||
| City: | OAK HARBOR | ||||||||
| State: | OH | ||||||||
| PostalCode: | 434491541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4195595591 | ||||||||
| FaxNumber: | 8662685006 | ||||||||
| Practice Location | |||||||||
| Address1: | 3232 NAVARRE AVE | ||||||||
| Address2: | |||||||||
| City: | OREGON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436163312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4195595591 | ||||||||
| FaxNumber: | 8662685006 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2012 | ||||||||
| LastUpdateDate: | 09/28/2012 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HALLETT | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4195595591 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | II | ||||||||
| AuthorizedOfficialCredential: | PT, DPT | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 10498 | OH | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 3110369 | 05 | OH | MEDICAID |