Basic Information
Provider Information | |||||||||
NPI: | 1730463993 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MALO | ||||||||
FirstName: | NATHANIEL | ||||||||
MiddleName: | J | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DPT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 5718 | ||||||||
Address2: |   | ||||||||
City: | KALISPELL | ||||||||
State: | MT | ||||||||
PostalCode: | 599035718 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4067560134 | ||||||||
FaxNumber: | 4063001612 | ||||||||
Practice Location | |||||||||
Address1: | 4216 WASHINGTON RD STE 2 | ||||||||
Address2: |   | ||||||||
City: | EVANS | ||||||||
State: | GA | ||||||||
PostalCode: | 308094717 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7068145460 | ||||||||
FaxNumber: | 7068145574 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/06/2011 | ||||||||
LastUpdateDate: | 07/01/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/01/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT015742 | GA | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   | 225100000X | PT 38220 | CA | N |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
No ID Information.