MEDICARE: MS. MALA JEAN WALLER PT

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	225100000X	Physical Therapist	336	AR

General Provider Information

NPI Number	:	1568553212
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MALA JEAN WALLER PT

Provider Business Mailing Address
First Line	:	2200 FORT ROOTS DRIVE
Second Line	:
City	:	N LITTLE ROCK
State	:	AR
Zip	:	72214
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2200 FORT ROOTS DR
Second Line	:
City	:	N LITTLE ROCK
State	:	AR
Zip	:	72114-1709
Country	:	US
Telephone Number	:	501-257-1046
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/27/2006
Last Update Date	:	07/08/2007

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