Provider Demographics
NPI:1063254068
Name:BALLESTEROS, MALACHI ZION
Entity type:Individual
Prefix:
First Name:MALACHI
Middle Name:ZION
Last Name:BALLESTEROS
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 1:2013 WHITE FALLS ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-6751
Mailing Address - Country:US
Mailing Address - Phone:702-755-7125
Mailing Address - Fax:
Practice Address - Street 1:2013 WHITE FALLS ST
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-6751
Practice Address - Country:US
Practice Address - Phone:702-755-7125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-10
Last Update Date:2024-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer