Healthcare Provider Details

I. General information

NPI: 1942746185
Provider Name (Legal Business Name): MARLON PEMBERTON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/11/2017
Last Update Date: 01/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1604 VISA DR STE 1
NORMAL IL
61761-2195
US

IV. Provider business mailing address

1604 VISA DR STE 1
NORMAL IL
61761-2195
US

V. Phone/Fax

Practice location:
  • Phone: 309-454-1100
  • Fax: 309-454-1107
Mailing address:
  • Phone: 309-454-1100
  • Fax: 309-454-1107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246QM0706X
TaxonomyMedical Technologist
License Number246ZE0600X
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: