Healthcare Provider Details

I. General information

NPI: 1649711102
Provider Name (Legal Business Name): CALEB JOHN MARVIN CTRS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2017
Last Update Date: 03/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7794 PAINT CREEK DR
YPSILANTI MI
48197-6139
US

IV. Provider business mailing address

160 WHIPPLE ST
SOUTH LYON MI
48178-1114
US

V. Phone/Fax

Practice location:
  • Phone: 734-352-3543
  • Fax:
Mailing address:
  • Phone: 989-205-9663
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number68419
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: