Healthcare Provider Details

I. General information

NPI: 1245749035
Provider Name (Legal Business Name): MARVIN STEPHONE BENNETT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2017
Last Update Date: 09/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4825 SUECLA DR
RICHMOND VA
23231-2921
US

IV. Provider business mailing address

4825 SUECLA DR
RICHMOND VA
23231-2921
US

V. Phone/Fax

Practice location:
  • Phone: 804-475-0795
  • Fax: 804-226-7998
Mailing address:
  • Phone: 804-226-7998
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License NumberT62974258
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: