Provider Demographics
NPI:1235466350
Name:MALLARE, ROLAND FELICIANO
Entity Type:Individual
Prefix:MR
First Name:ROLAND
Middle Name:FELICIANO
Last Name:MALLARE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 E PELLS ST
Mailing Address - Street 2:
Mailing Address - City:PAXTON
Mailing Address - State:IL
Mailing Address - Zip Code:60957-1300
Mailing Address - Country:US
Mailing Address - Phone:217-379-4361
Mailing Address - Fax:
Practice Address - Street 1:1001 E PELLS ST
Practice Address - Street 2:
Practice Address - City:PAXTON
Practice Address - State:IL
Practice Address - Zip Code:60957-1300
Practice Address - Country:US
Practice Address - Phone:217-379-4361
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-10
Last Update Date:2015-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.005217225200000X
IL160005217225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant