MEDICARE: MALAMA MEDICAL GROUP

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	163WM0102X	Maternal Newborn Registered Nurse
2	133N00000X	Nutritionist
3	251B00000X	Case Management Agency
4	171M00000X	Case Manager/Care Coordinator
5	133VN1201X	Obesity and Weight Management Nutrition Registered Dietitian

General Provider Information

NPI Number	:	1912774167
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MALAMA MEDICAL GROUP

Provider Business Mailing Address
First Line	:	2261 MARKET ST # 4785
Second Line	:
City	:	SAN FRANCISCO
State	:	CA
Zip	:	94114-1612
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1942 BROADWAY ST.
Second Line	:	STE. 314C
City	:	BOULDER
State	:	CO
Zip	:	80302
Country	:	US
Telephone Number	:	949-424-5479
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	PRIYANKA WALI
Credential	:	MD
Telephone Number	:	408-256-3180

Provider Enumeration Date	:	12/07/2023
Last Update Date	:	03/20/2026

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