Healthcare Provider Details

I. General information

NPI: 1952639759
Provider Name (Legal Business Name): MARCUS STEVENSON LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/07/2009
Last Update Date: 12/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 SUMMER PARK RD
COLUMBIA SC
29223-7878
US

IV. Provider business mailing address

220 SUMMER PARK RD
COLUMBIA SC
29223-7878
US

V. Phone/Fax

Practice location:
  • Phone: 803-667-0460
  • Fax:
Mailing address:
  • Phone: 803-667-0460
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMAS. 6256
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: