Provider Demographics
NPI:1609260413
Name:HALL, MICHAEL (ATC)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:HALL
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 MCANDREWS RD W
Mailing Address - Street 2:APT 216
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337-5708
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8100 W 78TH ST
Practice Address - Street 2:SUITE #230
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55439-2516
Practice Address - Country:US
Practice Address - Phone:952-946-9777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-19
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN26632255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer