Provider Demographics
NPI:1184205247
Name:GREEN, MARVA SHARICA
Entity Type:Individual
Prefix:
First Name:MARVA
Middle Name:SHARICA
Last Name:GREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:528 BROAD ST STE 202
Mailing Address - Street 2:
Mailing Address - City:SUMTER
Mailing Address - State:SC
Mailing Address - Zip Code:29150-3368
Mailing Address - Country:US
Mailing Address - Phone:803-883-5047
Mailing Address - Fax:803-883-5047
Practice Address - Street 1:528 BROAD ST STE 202
Practice Address - Street 2:
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29150-3368
Practice Address - Country:US
Practice Address - Phone:803-883-5047
Practice Address - Fax:803-883-5047
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-19
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC251E00000X, 251T00000X
374U00000X, 251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No251T00000XAgenciesProgram of All-Inclusive Care for the Elderly (PACE) Provider Organization
No374U00000XNursing Service Related ProvidersHome Health Aide