Provider Demographics
NPI:1184953960
Name:MALONZO, LORALIE DIMACALI
Entity type:Individual
Prefix:
First Name:LORALIE
Middle Name:DIMACALI
Last Name:MALONZO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LORALIE
Other - Middle Name:
Other - Last Name:MALONZO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT
Mailing Address - Street 1:1920 OLD SPRINGVILLE ROAD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35215
Mailing Address - Country:US
Mailing Address - Phone:205-520-9600
Mailing Address - Fax:205-520-0455
Practice Address - Street 1:1920 OLD SPRINGVILLE RD
Practice Address - Street 2:SUITE 104
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35215
Practice Address - Country:US
Practice Address - Phone:800-854-4589
Practice Address - Fax:205-520-0455
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-08
Last Update Date:2009-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009032715225100000X
IL070.016201225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WW0042880OtherPHILIPPINE PASSPORT NUMBER