Provider Demographics
NPI:1871985762
Name:BROWN, MALCOLM (ATC,LAT)
Entity type:Individual
Prefix:
First Name:MALCOLM
Middle Name:
Last Name:BROWN
Suffix:
Gender:M
Credentials:ATC,LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 N PATTERSON ST
Mailing Address - Street 2:ATHLETIC FIELD HOUSE ROOM 1018
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31698-0100
Mailing Address - Country:US
Mailing Address - Phone:229-333-5897
Mailing Address - Fax:
Practice Address - Street 1:1500 N PATTERSON ST
Practice Address - Street 2:ATHLETIC FIELD HOUSE ROOM 1018
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31698-0100
Practice Address - Country:US
Practice Address - Phone:229-333-5897
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-02
Last Update Date:2015-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0023072255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer