Basic Information
| Provider Information | |||||||||
| NPI: | 1386774214 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MALCOLM | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | MICHAEL | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | ADC CERT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4109 MONROE ST | ||||||||
| Address2: | |||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925042965 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9513527669 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 160 E HOLT AVE STE B | ||||||||
| Address2: | |||||||||
| City: | POMONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917675407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9096202521 | ||||||||
| FaxNumber: | 9096209793 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225400000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner |
No ID Information.