Provider Demographics
NPI:1003532946
Name:KING, MARVIN BRIEN
Entity Type:Individual
Prefix:
First Name:MARVIN
Middle Name:BRIEN
Last Name:KING
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:367 GOLFCREST DR SE
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30094-3639
Mailing Address - Country:US
Mailing Address - Phone:248-694-1328
Mailing Address - Fax:678-509-5315
Practice Address - Street 1:367 GOLFCREST DR SE
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30094-3639
Practice Address - Country:US
Practice Address - Phone:248-694-1328
Practice Address - Fax:678-509-5315
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-12
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA21141461343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)