Provider Demographics
NPI:1285023341
Name:HALLAM, KURTIS
Entity Type:Individual
Prefix:
First Name:KURTIS
Middle Name:
Last Name:HALLAM
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 1:1620 LEAD HILL BLVD
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-2853
Mailing Address - Country:US
Mailing Address - Phone:916-789-1111
Mailing Address - Fax:
Practice Address - Street 1:1620 LEAD HILL BLVD
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-2853
Practice Address - Country:US
Practice Address - Phone:916-789-1111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-13
Last Update Date:2017-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT421262251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ18712ZMedicare PIN