Healthcare Provider Details

I. General information

NPI: 1679979868
Provider Name (Legal Business Name): THOMAS MALONE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2014
Last Update Date: 11/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 E AZTEC AVE
GALLUP NM
87301-5509
US

IV. Provider business mailing address

PO BOX 264
GALLUP NM
87305-0264
US

V. Phone/Fax

Practice location:
  • Phone: 505-721-1856
  • Fax:
Mailing address:
  • Phone: 505-906-5291
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License NumberX-08961
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: