Provider Demographics
NPI:1902031644
Name:WARREN, MALCOLM JR (DC)
Entity Type:Individual
Prefix:DR
First Name:MALCOLM
Middle Name:
Last Name:WARREN
Suffix:JR
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3823 ROSWELL RD., STE 202
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062
Mailing Address - Country:US
Mailing Address - Phone:678-383-6643
Mailing Address - Fax:
Practice Address - Street 1:3823 ROSWELL RD STE 202
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062
Practice Address - Country:US
Practice Address - Phone:678-383-6643
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-26
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC31271111N00000X
GA225100000X, 2251X0800X
GACHIR009614111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC31271OtherCHIROPRACTIC LICENSE