Provider Demographics
NPI:1497201271
Name:THEODORE, MALIDA
Entity Type:Individual
Prefix:
First Name:MALIDA
Middle Name:
Last Name:THEODORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57 OSCAR AVE
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02302-1047
Mailing Address - Country:US
Mailing Address - Phone:617-283-6211
Mailing Address - Fax:
Practice Address - Street 1:57 OSCAR AVE
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02302-1047
Practice Address - Country:US
Practice Address - Phone:617-283-6211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-31
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide