Healthcare Provider Details

I. General information

NPI: 1518507219
Provider Name (Legal Business Name): MALCOLM BANKS CDCA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2020
Last Update Date: 01/10/2020
Certification Date: 01/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5301 NEBRASKA AVE. NEW CONCEPTS
TOLEDO OH
43615
US

IV. Provider business mailing address

PO BOX 20068
TOLEDO OH
43610-0068
US

V. Phone/Fax

Practice location:
  • Phone: 419-206-0171
  • Fax:
Mailing address:
  • Phone: 419-531-5544
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberCDCA.172408
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: