Healthcare Provider Details

I. General information

NPI: 1154323020
Provider Name (Legal Business Name): TRACY L MALAN RPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2005
Last Update Date: 08/15/2007
Certification Date:
Deactivation Date: 03/23/2006
Reactivation Date: 04/06/2006

III. Provider practice location address

525 MELISSA AVE STE B
BARSTOW CA
92311-3002
US

IV. Provider business mailing address

525 MELISSA AVE STE B
BARSTOW CA
92311-3002
US

V. Phone/Fax

Practice location:
  • Phone: 760-256-1888
  • Fax: 760-256-2893
Mailing address:
  • Phone: 760-256-1888
  • Fax: 760-256-2893

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT12940
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: