Provider Demographics
NPI:1275004996
Name:MALLOY, CHRISTOPHER
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:
Last Name:MALLOY
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 1:85 SEQUOIA LN
Mailing Address - Street 2:
Mailing Address - City:NORTH WATERBORO
Mailing Address - State:ME
Mailing Address - Zip Code:04061-4946
Mailing Address - Country:US
Mailing Address - Phone:207-808-1446
Mailing Address - Fax:
Practice Address - Street 1:85 SEQUOIA LN
Practice Address - Street 2:
Practice Address - City:NORTH WATERBORO
Practice Address - State:ME
Practice Address - Zip Code:04061-4946
Practice Address - Country:US
Practice Address - Phone:207-808-1446
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-06
Last Update Date:2018-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor