Healthcare Provider Details

I. General information

NPI: 1013604792
Provider Name (Legal Business Name): DUANE C MALO LAT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2023
Last Update Date: 04/21/2023
Certification Date: 04/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 17TH AVE E STE 101
ALEXANDRIA MN
56308-5274
US

IV. Provider business mailing address

1880 10TH AVE E APT 217
ALEXANDRIA MN
56308-2719
US

V. Phone/Fax

Practice location:
  • Phone: 320-762-1144
  • Fax:
Mailing address:
  • Phone: 773-251-0095
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: