1013054758 NPI number — DR. ROBERT BRUCE MALL D.C.,B.C.A.O.

Table of content: DR. ROBERT BRUCE MALL D.C.,B.C.A.O. (NPI 1013054758)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013054758 NPI number — DR. ROBERT BRUCE MALL D.C.,B.C.A.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MALL
Provider First Name:
ROBERT
Provider Middle Name:
BRUCE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.C.,B.C.A.O.
Provider Gender Code:
M

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:
1013054758
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3665 WHEELER RD
Provider Second Line Business Mailing Address:
STE 2A
Provider Business Mailing Address City Name:
AUGUSTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30909-6603
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-860-8717
Provider Business Mailing Address Fax Number:
706-860-1341

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3665 WHEELER RD
Provider Second Line Business Practice Location Address:
STE 2A
Provider Business Practice Location Address City Name:
AUGUSTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30909-6603
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-860-8717
Provider Business Practice Location Address Fax Number:
706-860-1341
Provider Enumeration Date:
01/31/2007

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: 111N00000X , with the licence number:  CHIR007931 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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