1215201215 NPI number — VINCENT D. MALLORY MD., LLC

Table of content: (NPI 1215201215)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215201215 NPI number — VINCENT D. MALLORY MD., LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VINCENT D. MALLORY MD., LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1215201215
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/08/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3311 PRESCOTT RD
Provider Second Line Business Mailing Address:
SUITE 316
Provider Business Mailing Address City Name:
ALEXANDRIA
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71301-3900
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-487-1717
Provider Business Mailing Address Fax Number:
318-487-1170

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3311 PRESCOTT RD
Provider Second Line Business Practice Location Address:
SUITE 316
Provider Business Practice Location Address City Name:
ALEXANDRIA
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71301-3900
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-487-1717
Provider Business Practice Location Address Fax Number:
318-487-1170
Provider Enumeration Date:
03/08/2012

Additional Information

Authorized Official

Authorized Official Last Name:
MALLORY
Authorized Official First Name:
CONSTANCE
Authorized Official Middle Name:
FISHER
Authorized Official Title or Position:
OFFICE MANGER
Authorized Official Telephone Number:
318-487-1717

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1574520 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1215918503 . This is a "NPI-INDIVIDUAL" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".




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