Healthcare Provider Details

I. General information

NPI: 1912403064
Provider Name (Legal Business Name): MARVIN BALDWIN JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2018
Last Update Date: 04/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1090 UPPER HEMBREE RD
ROSWELL GA
30076-1140
US

IV. Provider business mailing address

1090 UPPER HEMBREE RD
ROSWELL GA
30076-1140
US

V. Phone/Fax

Practice location:
  • Phone: 678-744-7512
  • Fax:
Mailing address:
  • Phone: 678-744-7512
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code173C00000X
TaxonomyReflexologist
License NumberMT009371
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT009371
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code172A00000X
TaxonomyDriver
License Number054444544
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: