Provider Demographics
NPI:1528635471
Name:HALL, CHARLES TUCKER (SOIDC)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:TUCKER
Last Name:HALL
Suffix:
Gender:M
Credentials:SOIDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2D MARINE DIVISION, 2D RECONNAISSANCE BATTALION
Mailing Address - Street 2:PSC BOX 20138
Mailing Address - City:CAMP LEJUNE
Mailing Address - State:NC
Mailing Address - Zip Code:28542-0138
Mailing Address - Country:US
Mailing Address - Phone:414-514-5304
Mailing Address - Fax:
Practice Address - Street 1:2D MARINE DIVISION
Practice Address - Street 2:2D RECONNAISSANCE BATTALION
Practice Address - City:CAMP LEJUNE
Practice Address - State:NC
Practice Address - Zip Code:28542-0138
Practice Address - Country:US
Practice Address - Phone:414-514-5304
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-09
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman