Healthcare Provider Details

I. General information

NPI: 1275004996
Provider Name (Legal Business Name): CHRISTOPHER MALLOY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/06/2018
Last Update Date: 12/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

85 SEQUOIA LN
NORTH WATERBORO ME
04061-4946
US

IV. Provider business mailing address

85 SEQUOIA LN
NORTH WATERBORO ME
04061-4946
US

V. Phone/Fax

Practice location:
  • Phone: 207-808-1446
  • Fax:
Mailing address:
  • Phone: 207-808-1446
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: