Provider Demographics
NPI:1366127334
Name:HALLEM, ETHAN ALLAN
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:ALLAN
Last Name:HALLEM
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 1:949 S BLAINE AVE APT 8
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57103-2861
Mailing Address - Country:US
Mailing Address - Phone:605-321-0197
Mailing Address - Fax:
Practice Address - Street 1:949 S BLAINE AVE APT 8
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57103-2861
Practice Address - Country:US
Practice Address - Phone:605-321-0197
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-19
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care