Basic Information
| Provider Information | |||||||||
| NPI: | 1992184659 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MALILAY | ||||||||
| FirstName: | JONATHAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 33900 HARPER AVE | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | CLINTON TOWNSHIP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480354258 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5864169100 | ||||||||
| FaxNumber: | 5864169103 | ||||||||
| Practice Location | |||||||||
| Address1: | 25311 LITTLE MACK AVE | ||||||||
| Address2: | STE A | ||||||||
| City: | SAINT CLAIR SHORES | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480813301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5867714900 | ||||||||
| FaxNumber: | 5867714913 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2015 | ||||||||
| LastUpdateDate: | 01/03/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 5501017101 | MI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.