Healthcare Provider Details

I. General information

NPI: 1386261758
Provider Name (Legal Business Name): MALLORY GRACE HUFF
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2020
Last Update Date: 07/01/2020
Certification Date: 07/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 LAURENCE AVE
JACKSON MI
49202-2979
US

IV. Provider business mailing address

4810 BLACKMAN RD
JACKSON MI
49201-9464
US

V. Phone/Fax

Practice location:
  • Phone: 517-750-4777
  • Fax:
Mailing address:
  • Phone: 517-414-1939
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: