Healthcare Provider Details

I. General information

NPI: 1063356590
Provider Name (Legal Business Name): MARVIN RAY GAINES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2026
Last Update Date: 04/15/2026
Certification Date: 04/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

37070 BRYNFORD DR
CLINTON TOWNSHIP MI
48036-4412
US

IV. Provider business mailing address

37070 BRYNFORD DR
CLINTON TOWNSHIP MI
48036-4412
US

V. Phone/Fax

Practice location:
  • Phone: 586-457-8484
  • Fax:
Mailing address:
  • Phone: 586-457-8484
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: