Provider Demographics
NPI:1184178535
Name:HALL, DAVID MADISON
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:MADISON
Last Name:HALL
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 1:239 S LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:RUSSELL
Mailing Address - State:KS
Mailing Address - Zip Code:67665-2907
Mailing Address - Country:US
Mailing Address - Phone:434-661-7637
Mailing Address - Fax:
Practice Address - Street 1:1201 CORPORATE BLVD STE 130
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89502-7162
Practice Address - Country:US
Practice Address - Phone:775-828-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-14
Last Update Date:2016-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS14-03054225200000X
VA2306604493225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant