Provider Demographics
NPI:1174261838
Name:HALLIBURTON, TORIAN LESHUN
Entity Type:Individual
Prefix:
First Name:TORIAN
Middle Name:LESHUN
Last Name:HALLIBURTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4828 ESTY RD
Mailing Address - Street 2:
Mailing Address - City:BARTLETT
Mailing Address - State:TN
Mailing Address - Zip Code:38002-5987
Mailing Address - Country:US
Mailing Address - Phone:901-283-9066
Mailing Address - Fax:
Practice Address - Street 1:4828 ESTY RD
Practice Address - Street 2:
Practice Address - City:BARTLETT
Practice Address - State:TN
Practice Address - Zip Code:38002-5987
Practice Address - Country:US
Practice Address - Phone:901-283-9066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-23
Last Update Date:2022-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN096141378172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver