Provider Demographics
NPI:1679173512
Name:HALL, CHARLES CLARK I
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:CLARK
Last Name:HALL
Suffix:I
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:PO BOX 103
Mailing Address - Street 2:
Mailing Address - City:CHESTERLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44026-0103
Mailing Address - Country:US
Mailing Address - Phone:440-781-9448
Mailing Address - Fax:
Practice Address - Street 1:8210 BELLE VERNON DR
Practice Address - Street 2:
Practice Address - City:NOVELTY
Practice Address - State:OH
Practice Address - Zip Code:44072-9700
Practice Address - Country:US
Practice Address - Phone:440-781-9448
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-29
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2801936376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2801936Medicaid