MEDICARE: MALLORY & WHITE PC

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	261Q00000X	Clinic/Center	978	OR

General Provider Information

NPI Number	:	1679070437
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MALLORY & WHITE PC

Provider Business Mailing Address
First Line	:	619 MADISON ST STE 108
Second Line	:
City	:	OREGON CITY
State	:	OR
Zip	:	97045-2354
Country	:	US
Telephone Number	:	503-303-4257
Fax Number	:

Provider Business Practice Location Address
First Line	:	619 MADISON ST STE 108
Second Line	:
City	:	OREGON CITY
State	:	OR
Zip	:	97045-2354
Country	:	US
Telephone Number	:	503-303-4257
Fax Number	:

Authorized Official
Title or Position	:	PROVIDER
Name	:	LOREN MALLORY
Credential	:	PHD, ABPP
Telephone Number	:	503-303-4257

Provider Enumeration Date	:	04/09/2018
Last Update Date	:	04/09/2018

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Directions to “MALLORY & WHITE PC ” Practice Location

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