Provider Demographics
NPI:1619045473
Name:MALLORY OSTEOPATHIC FAMILY PRACTICE
Entity Type:Organization
Organization Name:MALLORY OSTEOPATHIC FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:LAWRENCE
Authorized Official - Last Name:MALLORY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:970-669-9245
Mailing Address - Street 1:1548 N BOISE AVENUE
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80538-4125
Mailing Address - Country:US
Mailing Address - Phone:970-669-9245
Mailing Address - Fax:970-669-9247
Practice Address - Street 1:1548 N BOISE AVENUE
Practice Address - Street 2:
Practice Address - City:LOVELAND
Practice Address - State:CO
Practice Address - Zip Code:80538-4125
Practice Address - Country:US
Practice Address - Phone:970-669-9245
Practice Address - Fax:970-669-9247
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2008-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO40960207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO801998Medicare ID - Type Unspecified
COC801998Medicare PIN