Basic Information
| Provider Information | |||||||||
| NPI: | 1659835825 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MALLORY | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | DAVID | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 30516 | ||||||||
| Address2: | DEPT 5300 | ||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3864535225 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5570 WILSON AVE SW | ||||||||
| Address2: | SUITE A | ||||||||
| City: | GRANDVILLE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49418 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6168551495 | ||||||||
| FaxNumber: | 6168551496 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2019 | ||||||||
| LastUpdateDate: | 08/02/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 11564 | TN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.