Provider Demographics
NPI:1609343474
Name:SCRUGGS, MARVINA
Entity Type:Individual
Prefix:
First Name:MARVINA
Middle Name:
Last Name:SCRUGGS
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 1:379 E 47TH ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32208-5463
Mailing Address - Country:US
Mailing Address - Phone:904-726-7970
Mailing Address - Fax:
Practice Address - Street 1:379 E 47TH ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32208-5463
Practice Address - Country:US
Practice Address - Phone:904-726-7970
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-30
Last Update Date:2018-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251E00000X, 261QD1600X, 374U00000X, 385H00000X
FL235397372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
No251E00000XAgenciesHome Health
No372600000XNursing Service Related ProvidersAdult Companion
No374U00000XNursing Service Related ProvidersHome Health Aide
No385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL81-1835965OtherIRS