Provider Demographics
NPI:1619478021
Name:HALL, NICHOLAS L
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:L
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 1:2408 ARGILLITE RD APT 2
Mailing Address - Street 2:
Mailing Address - City:FLATWOODS
Mailing Address - State:KY
Mailing Address - Zip Code:41139-1384
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2954 WALNUT ST
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:OH
Practice Address - Zip Code:45662-4828
Practice Address - Country:US
Practice Address - Phone:740-353-1111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-22
Last Update Date:2018-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.165217171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator