Healthcare Provider Details

I. General information

NPI: 1376085837
Provider Name (Legal Business Name): MONICA MALCOME LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2016
Last Update Date: 11/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1932 S MAIN ST
EUREKA IL
61530-1666
US

IV. Provider business mailing address

1198 MAPLE LN
EAST PEORIA IL
61611-1236
US

V. Phone/Fax

Practice location:
  • Phone: 309-467-5000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number227.016045
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: