Healthcare Provider Details

I. General information

NPI: 1184548604
Provider Name (Legal Business Name): MARVIN CARTER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2026
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16223 STAR CREST WAY
FONTANA CA
92336-1472
US

IV. Provider business mailing address

16223 STAR CREST WAY
FONTANA CA
92336-1472
US

V. Phone/Fax

Practice location:
  • Phone: 909-917-6243
  • Fax:
Mailing address:
  • Phone: 909-917-6243
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number141095
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: