Provider Demographics
NPI:1043627771
Name:MARION, MAX W (CSA)
Entity Type:Individual
Prefix:MR
First Name:MAX
Middle Name:W
Last Name:MARION
Suffix:
Gender:M
Credentials:CSA
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1945 SCOTTSVILLE RD
Mailing Address - Street 2:B2 PMB137
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42104-3376
Mailing Address - Country:US
Mailing Address - Phone:270-782-0434
Mailing Address - Fax:270-782-0564
Practice Address - Street 1:1725 ASHLEY CIR
Practice Address - Street 2:SUITE 212
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104-3337
Practice Address - Country:US
Practice Address - Phone:270-782-0434
Practice Address - Fax:270-782-0564
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-15
Last Update Date:2014-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYSA272174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist