Provider Demographics
NPI:1194828228
Name:MALLE, MICHAEL PHILLIP (LMT)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:PHILLIP
Last Name:MALLE
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5975 NORTH FEDERAL HIGHWAY
Mailing Address - Street 2:SUITE 244
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-2652
Mailing Address - Country:US
Mailing Address - Phone:954-491-7606
Mailing Address - Fax:954-491-8238
Practice Address - Street 1:5975 NORTH FEDERAL HIGHWAY
Practice Address - Street 2:SUITE 244
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-2652
Practice Address - Country:US
Practice Address - Phone:954-491-7606
Practice Address - Fax:954-491-8238
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA0018174225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLC6627OtherBCBS