MEDICARE: MALLKU, LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number State
1	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility	TX
2	320700000X	Physical Disabilities Residential Treatment Facility	TX
3	320800000X	Mental Illness Community Based Residential Treatment Facility	TX
4	323P00000X	Psychiatric Residential Treatment Facility	TX
5	324500000X	Substance Abuse Rehabilitation Facility	TX
6	3245S0500X	Children's Substance Abuse Rehabilitation Facility	TX
7	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility	TX

General Provider Information

NPI Number	:	1407149545
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MALLKU, LLC

Provider Business Mailing Address
First Line	:	28 MONDAVI
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78258-4670
Country	:	US
Telephone Number	:	210-387-2599
Fax Number	:

Provider Business Practice Location Address
First Line	:	28 MONDAVI
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78258-4670
Country	:	US
Telephone Number	:	210-387-2599
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	ENRIQUE LIRA
Credential	:
Telephone Number	:	210-387-2599

Provider Enumeration Date	:	05/23/2011
Last Update Date	:	05/23/2011

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Directions to “MALLKU, LLC ” Practice Location

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