Provider Demographics
NPI:1649651282
Name:HALL, KEITH
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:
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 1:1126 LAKE KNOLL DR NW
Mailing Address - Street 2:1126 LAKE KNOLL DR.
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047-8716
Mailing Address - Country:US
Mailing Address - Phone:678-914-8642
Mailing Address - Fax:
Practice Address - Street 1:1126 LAKE KNOLL DR NW
Practice Address - Street 2:1126 LAKE KNOLL DR.
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30047-8716
Practice Address - Country:US
Practice Address - Phone:678-914-8642
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-09
Last Update Date:2015-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT 001807225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist