MEDICARE: GLORIA MALLORY

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	171M00000X	Case Manager/Care Coordinator		OH

General Provider Information

NPI Number	:	1861120040
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GLORIA MALLORY

Provider Business Mailing Address
First Line	:	77 E WOODBURY DR STE 110
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45415-2853
Country	:	US
Telephone Number	:	937-371-5724
Fax Number	:

Provider Business Practice Location Address
First Line	:	77 E WOODBURY DR
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45415-2855
Country	:	US
Telephone Number	:	937-371-5724
Fax Number	:

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

Provider Enumeration Date	:	08/15/2022
Last Update Date	:	08/15/2022

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Directions to “ GLORIA MALLORY ” Practice Location

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