Provider Demographics
NPI:1114318235
Name:MALETTA, PHILLIP (DC)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:
Last Name:MALETTA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2863 W SHORE DR STE 114
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49424-9576
Mailing Address - Country:US
Mailing Address - Phone:616-399-6624
Mailing Address - Fax:
Practice Address - Street 1:2863 W SHORE DR STE 114
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49424-9576
Practice Address - Country:US
Practice Address - Phone:616-399-6624
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301010295111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2301010295OtherLICENSE