Provider Demographics
NPI:1568639615
Name:MARBLE MOUNTAIN HEALTH
Entity Type:Organization
Organization Name:MARBLE MOUNTAIN HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:PHILLIP
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:530-468-5766
Mailing Address - Street 1:11219 N HIGHWAY 3
Mailing Address - Street 2:
Mailing Address - City:FORT JONES
Mailing Address - State:CA
Mailing Address - Zip Code:96032-9731
Mailing Address - Country:US
Mailing Address - Phone:530-468-5766
Mailing Address - Fax:530-468-2023
Practice Address - Street 1:11219 N HIGHWAY 3
Practice Address - Street 2:
Practice Address - City:FORT JONES
Practice Address - State:CA
Practice Address - Zip Code:96032-9731
Practice Address - Country:US
Practice Address - Phone:530-468-5766
Practice Address - Fax:530-468-2023
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-08
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetricsGroup - Multi-Specialty