Provider Demographics
NPI:1235447210
Name:FAULKNER, MARLON
Entity Type:Individual
Prefix:MR
First Name:MARLON
Middle Name:
Last Name:FAULKNER
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 1:6058 W FULLERTON AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60639-2243
Mailing Address - Country:US
Mailing Address - Phone:773-828-6045
Mailing Address - Fax:773-473-4104
Practice Address - Street 1:6058 W FULLERTON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60639-2243
Practice Address - Country:US
Practice Address - Phone:773-828-6045
Practice Address - Fax:773-473-4104
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-23
Last Update Date:2010-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL10138PT343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)