Provider Demographics
NPI:1962089649
Name:HALL, CHARLES ALEXANDER (IDC)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:ALEXANDER
Last Name:HALL
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34101 FARENHOLT AVE BLDG 14
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92134-7000
Mailing Address - Country:US
Mailing Address - Phone:619-532-7968
Mailing Address - Fax:
Practice Address - Street 1:3D AABN BATTALION AID STAION
Practice Address - Street 2:BLDG 210735
Practice Address - City:CAMP PENDLETON
Practice Address - State:CA
Practice Address - Zip Code:92055
Practice Address - Country:US
Practice Address - Phone:760-725-2192
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-27
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program