Healthcare Provider Details

I. General information

NPI: 1598557266
Provider Name (Legal Business Name): MARC HURST
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/20/2025
Last Update Date: 05/20/2025
Certification Date: 05/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2737 AVON RIVER DR
VALRICO FL
33596-6518
US

IV. Provider business mailing address

2737 AVON RIVER DR
VALRICO FL
33596-6518
US

V. Phone/Fax

Practice location:
  • Phone: 317-400-8086
  • Fax: 317-400-8086
Mailing address:
  • Phone: 317-400-8086
  • Fax: 317-400-8086

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number14003937A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: