MEDICARE: MALLOY HOLDINGS, LLC

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	261QP2000X	Physical Therapy Clinic/Center	2010024372	MO

General Provider Information

NPI Number	:	1659783942
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MALLOY HOLDINGS, LLC

Provider Business Mailing Address
First Line	:	PO BOX 13
Second Line	:
City	:	BROOKFIELD
State	:	MO
Zip	:	64628-0013
Country	:	US
Telephone Number	:	660-258-7892
Fax Number	:	660-258-9829

Provider Business Practice Location Address
First Line	:	122 N MAIN ST
Second Line	:
City	:	BROOKFIELD
State	:	MO
Zip	:	64628-1643
Country	:	US
Telephone Number	:	660-258-7892
Fax Number	:

Authorized Official
Title or Position	:	OWNER, PHYSICAL THERAPIST
Name	:	STACIE NICOLE MALLOY
Credential	:	DPT
Telephone Number	:	660-258-8645

Provider Enumeration Date	:	05/21/2014
Last Update Date	:	05/21/2014

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