MEDICARE: MALLORY BALL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	172V00000X	Community Health Worker

General Provider Information

NPI Number	:	1235715376
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MALLORY BALL

Provider Business Mailing Address
First Line	:	1190 ROCK WOODS RD
Second Line	:
City	:	VALLEY GROVE
State	:	WV
Zip	:	26060-1039
Country	:	US
Telephone Number	:	304-551-3753
Fax Number	:

Provider Business Practice Location Address
First Line	:	1190 ROCK WOODS RD
Second Line	:
City	:	VALLEY GROVE
State	:	WV
Zip	:	26060-1039
Country	:	US
Telephone Number	:	304-551-3753
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/19/2021
Last Update Date	:	03/19/2021

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Directions to “ MALLORY BALL ” Practice Location

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