Provider Demographics
NPI:1790306884
Name:HALL, KEVIN WILLIS (PTA)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:WILLIS
Last Name:HALL
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1510 W CENTER ST
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:UT
Mailing Address - Zip Code:84320-1645
Mailing Address - Country:US
Mailing Address - Phone:435-770-8798
Mailing Address - Fax:
Practice Address - Street 1:1400 N 500 E
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-2455
Practice Address - Country:US
Practice Address - Phone:435-716-2882
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-30
Last Update Date:2020-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9037678-24022081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine