=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023702834
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MALLEY CHIROPRACTIC PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/05/2023
-----------------------------------------------------
Last Update Date | 06/05/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 937 TAHOE BLVD STE 205
-----------------------------------------------------
City | INCLINE VILLAGE
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89451-7412
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 775-298-2289
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 937 TAHOE BLVD STE 205
-----------------------------------------------------
City | INCLINE VILLAGE
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89451-7412
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 775-298-2289
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PROVIDER
-----------------------------------------------------
Name | JONATHAN MALLEY
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 774-272-2382
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------