Healthcare Provider Details

I. General information

NPI: 1871825539
Provider Name (Legal Business Name): MARVIN ODIE RIVERS BS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/05/2010
Last Update Date: 02/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

808 NW 115TH ST
OKLAHOMA CITY OK
73114-6900
US

IV. Provider business mailing address

808 NW 115TH ST
OKLAHOMA CITY OK
73114-6900
US

V. Phone/Fax

Practice location:
  • Phone: 405-808-9105
  • Fax: 405-216-5272
Mailing address:
  • Phone: 405-808-9105
  • Fax: 405-216-5272

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: