Healthcare Provider Details

I. General information

NPI: 1760780696
Provider Name (Legal Business Name): MARSHALL CALVERT NCLMP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/01/2011
Last Update Date: 03/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3085 EAST RUSSELL ROAD SUITE E
LAS VEGAS NV
89120-3482
US

IV. Provider business mailing address

8665 W FLAMINGO RD PMB #131-113
LAS VEGAS NV
89147-8621
US

V. Phone/Fax

Practice location:
  • Phone: 702-433-8333
  • Fax: 702-433-4632
Mailing address:
  • Phone: 253-320-5415
  • Fax: 877-503-6586

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number3071
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA00025067
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number2002000659
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: