Provider Demographics
NPI:1831630870
Name:HALLER, CARL MATTHEW
Entity type:Individual
Prefix:
First Name:CARL
Middle Name:MATTHEW
Last Name:HALLER
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 1:436 PAXON ST
Mailing Address - Street 2:
Mailing Address - City:HELENA
Mailing Address - State:MT
Mailing Address - Zip Code:59602-7738
Mailing Address - Country:US
Mailing Address - Phone:406-422-4224
Mailing Address - Fax:406-422-4422
Practice Address - Street 1:436 PAXON ST
Practice Address - Street 2:
Practice Address - City:HELENA
Practice Address - State:MT
Practice Address - Zip Code:59602-7738
Practice Address - Country:US
Practice Address - Phone:406-422-4224
Practice Address - Fax:406-422-4422
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-09
Last Update Date:2017-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTC279507332B00000X, 332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies