Provider Demographics
NPI:1457336117
Name:MALAVOLTI, JAMES JOSEPH (DC)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:JOSEPH
Last Name:MALAVOLTI
Suffix:
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 1:7918 N HALE AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-2048
Mailing Address - Country:US
Mailing Address - Phone:309-693-7887
Mailing Address - Fax:309-693-3898
Practice Address - Street 1:7918 N HALE AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-2048
Practice Address - Country:US
Practice Address - Phone:309-693-7887
Practice Address - Fax:309-693-3898
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-14
Last Update Date:2010-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038006725111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL038006725Medicaid
IL939680Medicare ID - Type UnspecifiedMEDICARE NUMBER
ILU10100Medicare UPIN