Provider Demographics
NPI:1215818356
Name:HALL, CLYDE
Entity type:Individual
Prefix:
First Name:CLYDE
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 1:5235 BEAGLE CLUB RD
Mailing Address - Street 2:
Mailing Address - City:FRAZIERS BOTTOM
Mailing Address - State:WV
Mailing Address - Zip Code:25082-9575
Mailing Address - Country:US
Mailing Address - Phone:681-424-6859
Mailing Address - Fax:
Practice Address - Street 1:5235 BEAGLE CLUB RD
Practice Address - Street 2:
Practice Address - City:FRAZIERS BOTTOM
Practice Address - State:WV
Practice Address - Zip Code:25082-9575
Practice Address - Country:US
Practice Address - Phone:681-424-6859
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-08
Last Update Date:2025-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide