Basic Information
| Provider Information | |||||||||
| NPI: | 1992932552 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HALL | ||||||||
| FirstName: | CHAD | ||||||||
| MiddleName: | DERICK | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2 W 10TH ST | ||||||||
| Address2: | |||||||||
| City: | MARCUS HOOK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190614513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6108598850 | ||||||||
| FaxNumber: | 6108597876 | ||||||||
| Practice Location | |||||||||
| Address1: | 26396 BAY FARM RD | ||||||||
| Address2: | BACK BAY PARK CENTER | ||||||||
| City: | LONG NECK | ||||||||
| State: | DE | ||||||||
| PostalCode: | 199664993 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3029479662 | ||||||||
| FaxNumber: | 3029479692 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2009 | ||||||||
| LastUpdateDate: | 09/28/2009 | ||||||||
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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 | 172V00000X | J2-0000674 | DE | Y | Other Service Providers | Community Health Worker |
No ID Information.