Healthcare Provider Details

I. General information

NPI: 1023513306
Provider Name (Legal Business Name): MARLIN WAYNE HARRIS PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2018
Last Update Date: 03/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55500 SOUTH CIRCLE DRIVE
IDYLLWILD CA
92549
US

IV. Provider business mailing address

PO BOX 3371
IDYLLWILD CA
92549-3371
US

V. Phone/Fax

Practice location:
  • Phone: 951-659-5163
  • Fax: 951-659-5691
Mailing address:
  • Phone: 951-852-4703
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number14726
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: