Healthcare Provider Details

I. General information

NPI: 1013770148
Provider Name (Legal Business Name): PROVIDER ON DEMAND LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2024
Last Update Date: 10/09/2024
Certification Date: 10/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1199 OLD LORENA RD
LORENA TX
76655-3176
US

IV. Provider business mailing address

1551 W CENTRAL AVE
TEMPLE TX
76504-4005
US

V. Phone/Fax

Practice location:
  • Phone: 757-642-5062
  • Fax: 737-270-7540
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DR. BRETT MARVEL
Title or Position: COO
Credential: MD
Phone: 737-747-2200