Provider Demographics
NPI:1386774214
Name:MALCOLM, THOMAS MICHAEL (ADC CERT)
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:MICHAEL
Last Name:MALCOLM
Suffix:
Gender:M
Credentials:ADC CERT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4109 MONROE ST
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92504-2965
Mailing Address - Country:US
Mailing Address - Phone:951-352-7669
Mailing Address - Fax:
Practice Address - Street 1:160 E HOLT AVE STE B
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-5407
Practice Address - Country:US
Practice Address - Phone:909-620-2521
Practice Address - Fax:909-620-9793
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner