=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467515908
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | VINCENT J MALBA D.C.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/18/2006
-----------------------------------------------------
Last Update Date | 11/20/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 248 EDISON ST
-----------------------------------------------------
City | CLIFTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07013-1358
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-777-0058
-----------------------------------------------------
Fax | 973-405-6529
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 248 EDISON ST
-----------------------------------------------------
City | CLIFTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07013-1358
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-777-0058
-----------------------------------------------------
Fax | 973-405-6529
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 38MC00576600
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | X009990-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------