Provider Demographics
NPI:1609761428
Name:COLEMAN, MALIK ROSHON
Entity type:Individual
Prefix:
First Name:MALIK
Middle Name:ROSHON
Last Name:COLEMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:440 ALPINE STREET
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786
Mailing Address - Country:US
Mailing Address - Phone:619-887-3816
Mailing Address - Fax:
Practice Address - Street 1:440 ALPINE STREET
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786
Practice Address - Country:US
Practice Address - Phone:619-887-3816
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-11
Last Update Date:2025-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA78959225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty