Provider Demographics
NPI:1033686290
Name:SCURLOCK, MARQUIS EDJUAN (MS, RDN, LD)
Entity Type:Individual
Prefix:
First Name:MARQUIS
Middle Name:EDJUAN
Last Name:SCURLOCK
Suffix:
Gender:M
Credentials:MS, RDN, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1150 DARLENE LN APT 293
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-1103
Mailing Address - Country:US
Mailing Address - Phone:601-842-6748
Mailing Address - Fax:
Practice Address - Street 1:1150 DARLENE LN APT 293
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-1103
Practice Address - Country:US
Practice Address - Phone:601-842-6748
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-25
Last Update Date:2018-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORLD-D-10191450133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered