Healthcare Provider Details

I. General information

NPI: 1699543892
Provider Name (Legal Business Name): MARVIN PEASAH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/18/2023
Last Update Date: 12/18/2023
Certification Date: 12/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3703 NATHANS WAY
GREENSBORO NC
27405-9815
US

IV. Provider business mailing address

3703 NATHANS WAY
GREENSBORO NC
27405-9815
US

V. Phone/Fax

Practice location:
  • Phone: 336-807-2335
  • Fax:
Mailing address:
  • Phone: 336-807-2335
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: