Provider Demographics
NPI:1720205990
Name:HALL, STACY LYNN (DC)
Entity Type:Individual
Prefix:DR
First Name:STACY
Middle Name:LYNN
Last Name:HALL
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13368 GREENBRIAR DR
Mailing Address - Street 2:
Mailing Address - City:GRAND HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49417-9156
Mailing Address - Country:US
Mailing Address - Phone:616-846-8882
Mailing Address - Fax:
Practice Address - Street 1:616 N BEACON BLVD
Practice Address - Street 2:
Practice Address - City:GRAND HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49417-1193
Practice Address - Country:US
Practice Address - Phone:616-846-8788
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301008523111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MISH008523OtherBLUE CROSS PROVIDER
MI200303109127AMedicaid
MI4463584Medicaid
MIN55270001Medicare PIN
MIU91974Medicare UPIN
MI4463584Medicaid