Provider Demographics
NPI:1215156955
Name:MALLEN, EDWARD J (DC)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:J
Last Name:MALLEN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7420 S DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33405-4812
Mailing Address - Country:US
Mailing Address - Phone:561-588-7780
Mailing Address - Fax:561-588-9655
Practice Address - Street 1:7420 S DIXIE HWY
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33405-4812
Practice Address - Country:US
Practice Address - Phone:561-588-7780
Practice Address - Fax:561-588-9655
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH7184111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL55468OtherBLUECROSSBLUESHIELD
FL55468AMedicaid
FLU64051Medicare UPIN
FL55468AMedicaid