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General NPI Number Information
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NPI Number | 1619294725
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Entity Type | Individual
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Provider Name | MELVIN MALLARI L.M.T, P.T.A
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Gender | Male
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Dates
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Enumeration Date | 04/28/2010
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Last Update Date | 08/27/2018
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Provider Practice Location Address
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Address Line | 3816 WATERSIDE DR
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City | ORANGE PARK
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State | FL
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Zip | 32073
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Country | US
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Telephone | 904-802-1421
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Fax |
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Provider Business Mailing Address
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Address Line | 3816 WATERSIDE DR
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City | ORANGE PARK
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State | FL
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Zip | 32073-6982
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Country | US
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Telephone | 904-802-1421
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | PTA26759
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | 2127861
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License Number State | TX
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