Provider Demographics
NPI:1821298027
Name:HALL, BRENT KARL
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:KARL
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 1:35746 HARPER AVE
Mailing Address - Street 2:
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48035-3212
Mailing Address - Country:US
Mailing Address - Phone:586-791-9203
Mailing Address - Fax:586-791-9204
Practice Address - Street 1:35746 HARPER AVE
Practice Address - Street 2:
Practice Address - City:CLINTON TWP
Practice Address - State:MI
Practice Address - Zip Code:48035-3212
Practice Address - Country:US
Practice Address - Phone:586-791-9203
Practice Address - Fax:586-791-9204
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-25
Last Update Date:2007-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501009471225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist