Healthcare Provider Details

I. General information

NPI: 1457699076
Provider Name (Legal Business Name): MARVMED LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2013
Last Update Date: 01/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 E MOODY BLVD
BUNNELL FL
32110-5916
US

IV. Provider business mailing address

1400 E MOODY BLVD
BUNNELL FL
32110-5916
US

V. Phone/Fax

Practice location:
  • Phone: 386-237-4003
  • Fax:
Mailing address:
  • Phone: 386-237-4003
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: ROY CARLISI
Title or Position: CEO
Credential:
Phone: 386-237-4003