Healthcare Provider Details

I. General information

NPI: 1932687886
Provider Name (Legal Business Name): JOHNTAVIS LAMAR MALLARY PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2018
Last Update Date: 09/12/2025
Certification Date: 09/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1991 FORDHAM DR STE 102
FAYETTEVILLE NC
28304-3774
US

IV. Provider business mailing address

625 KENMOOR AVE SE STE 100
GRAND RAPIDS MI
49546-2395
US

V. Phone/Fax

Practice location:
  • Phone: 910-484-4653
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberP18256
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: