Healthcare Provider Details

I. General information

NPI: 1457518052
Provider Name (Legal Business Name): MARVIN ALEXANDER STALLWORTH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2008
Last Update Date: 05/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

339 E MAIN ST STE 203
ROCK HILL SC
29730-5367
US

IV. Provider business mailing address

339 E MAIN ST STE 203
ROCK HILL SC
29730-5367
US

V. Phone/Fax

Practice location:
  • Phone: 803-746-7749
  • Fax: 803-746-7748
Mailing address:
  • Phone: 803-746-7749
  • Fax: 803-746-7748

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: