Provider Demographics
NPI:1598423733
Name:HALE, TAYLOR J (IDC)
Entity Type:Individual
Prefix:MR
First Name:TAYLOR
Middle Name:J
Last Name:HALE
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3D RECON BN
Mailing Address - Street 2:UNIT 36180
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:96389-6180
Mailing Address - Country:US
Mailing Address - Phone:315-625-2484
Mailing Address - Fax:
Practice Address - Street 1:3D RECON BN
Practice Address - Street 2:UNIT 36180
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96389-6180
Practice Address - Country:US
Practice Address - Phone:315-625-2484
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-06
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman