Healthcare Provider Details

I. General information

NPI: 1649997537
Provider Name (Legal Business Name): MARCUS FORTSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/21/2022
Last Update Date: 10/22/2022
Certification Date: 10/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 KAMINER WAY PKWY STE F
COLUMBIA SC
29210-3986
US

IV. Provider business mailing address

120 KAMINER WAY PKWY STE F
COLUMBIA SC
29210-3986
US

V. Phone/Fax

Practice location:
  • Phone: 803-401-5673
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: