MEDICARE: MARVIN ALEXANDER STALLWORTH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	374U00000X	Home Health Aide

General Provider Information

NPI Number	:	1457518052
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARVIN ALEXANDER STALLWORTH

Provider Business Mailing Address
First Line	:	339 E MAIN ST STE 203
Second Line	:
City	:	ROCK HILL
State	:	SC
Zip	:	29730-5367
Country	:	US
Telephone Number	:	803-746-7749
Fax Number	:	803-746-7748

Provider Business Practice Location Address
First Line	:	339 E MAIN ST STE 203
Second Line	:
City	:	ROCK HILL
State	:	SC
Zip	:	29730-5367
Country	:	US
Telephone Number	:	803-746-7749
Fax Number	:	803-746-7748

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/21/2008
Last Update Date	:	05/21/2008

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Directions to “ MARVIN ALEXANDER STALLWORTH ” Practice Location

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