Provider Demographics
NPI:1427198514
Name:HALL, TRACY ROGERS (PT)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:ROGERS
Last Name:HALL
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:M
Other - Last Name:ROGERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:
Practice Address - Street 1:36 S MAIN ST
Practice Address - Street 2:STE B
Practice Address - City:TRAVELERS REST
Practice Address - State:SC
Practice Address - Zip Code:29690-1872
Practice Address - Country:US
Practice Address - Phone:864-660-8200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2015-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1092225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCTH0919Medicaid
SCQ32198Medicare UPIN