Provider Demographics
NPI:1518793900
Name:MALONE, TARVIS LEE
Entity type:Individual
Prefix:
First Name:TARVIS
Middle Name:LEE
Last Name:MALONE
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:TARVIS
Other - Middle Name:LEE
Other - Last Name:MALONE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:67 OTTAWA LANDINGS DR APT 304
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43607-2436
Mailing Address - Country:US
Mailing Address - Phone:419-260-7532
Mailing Address - Fax:
Practice Address - Street 1:500 MADISON AVE STE 605
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43604-1241
Practice Address - Country:US
Practice Address - Phone:567-312-8700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-11
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator