Provider Demographics
NPI:1649883364
Name:MARK J MALY ESTATE
Entity type:Organization
Organization Name:MARK J MALY ESTATE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:BOSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-789-4611
Mailing Address - Street 1:PO BOX 456
Mailing Address - Street 2:
Mailing Address - City:ORANGEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61060-0456
Mailing Address - Country:US
Mailing Address - Phone:815-789-4611
Mailing Address - Fax:815-789-4612
Practice Address - Street 1:103 S MAIN ST # PO
Practice Address - Street 2:
Practice Address - City:ORANGEVILLE
Practice Address - State:IL
Practice Address - Zip Code:61060-9244
Practice Address - Country:US
Practice Address - Phone:815-789-4611
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-24
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental