MEDICARE: SHILOH VALLEY CLINIC LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner

General Provider Information

NPI Number	:	1497698104
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHILOH VALLEY CLINIC LLC

Provider Business Mailing Address
First Line	:	707 WHITLOCK AVE SW
Second Line	:
City	:	MARIETTA
State	:	GA
Zip	:	30064-3000
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	707 WHITLOCK AVE SW
Second Line	:
City	:	MARIETTA
State	:	GA
Zip	:	30064-3000
Country	:	US
Telephone Number	:	765-326-0148
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT/CEO
Name	:	BRANDERLY MALIWA
Credential	:
Telephone Number	:	765-326-0148

Provider Enumeration Date	:	04/09/2026
Last Update Date	:	04/09/2026

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Directions to “SHILOH VALLEY CLINIC LLC ” Practice Location

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