1275588634 NPI number — KELLY M MALENA PA C

Table of content: KELLY M MALENA PA C (NPI 1275588634)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275588634 NPI number — KELLY M MALENA PA C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MALENA
Provider First Name:
KELLY
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
VAVRO
Provider Other First Name:
KELLY
Provider Other Middle Name:
M
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1275588634
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/16/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
ONE INDEPENDENCE POINTE
Provider Second Line Business Mailing Address:
SUITE 212
Provider Business Mailing Address City Name:
GREENVILLE
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29615-4566
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
864-797-6044
Provider Business Mailing Address Fax Number:
864-797-6198

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 PATEWOOD DR
Provider Second Line Business Practice Location Address:
SUITE C300
Provider Business Practice Location Address City Name:
GREENVILLE
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29615-3593
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-454-8272
Provider Business Practice Location Address Fax Number:
864-454-2875
Provider Enumeration Date:
05/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  1085 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363AS0400X , with the licence number: 1085 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1085 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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