Provider Demographics
NPI:1164167987
Name:MALLES, NICHOLAS ARISTON III (DC)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:ARISTON
Last Name:MALLES
Suffix:III
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 1:24725 W 12 MILE RD STE 260
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-8310
Mailing Address - Country:US
Mailing Address - Phone:248-353-2225
Mailing Address - Fax:248-353-2239
Practice Address - Street 1:24725 W 12 MILE RD STE 260
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-8310
Practice Address - Country:US
Practice Address - Phone:248-353-2225
Practice Address - Fax:248-353-2239
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-05
Last Update Date:2022-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301401256111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2301401256OtherCHIROPRACTIC LICENSE