Provider Demographics
NPI:1659783942
Name:MALLOY HOLDINGS, LLC
Entity Type:Organization
Organization Name:MALLOY HOLDINGS, LLC
Other - Org Name:BROOKFIELD PHYISCAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER, PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:STACIE
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:MALLOY
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:660-258-8645
Mailing Address - Street 1:PO BOX 13
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:64628-0013
Mailing Address - Country:US
Mailing Address - Phone:660-258-7892
Mailing Address - Fax:660-258-9829
Practice Address - Street 1:122 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:MO
Practice Address - Zip Code:64628-1643
Practice Address - Country:US
Practice Address - Phone:660-258-7892
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-21
Last Update Date:2014-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010024372261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy