Provider Demographics
NPI:1710094933
Name:MARVIN, KENNETH RUSSELL (DC)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:RUSSELL
Last Name:MARVIN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37 E CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:PEARL RIVER
Mailing Address - State:NY
Mailing Address - Zip Code:10965-2306
Mailing Address - Country:US
Mailing Address - Phone:845-735-4755
Mailing Address - Fax:
Practice Address - Street 1:37 E CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:PEARL RIVER
Practice Address - State:NY
Practice Address - Zip Code:10965-2306
Practice Address - Country:US
Practice Address - Phone:845-735-4755
Practice Address - Fax:845-735-1055
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2008-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX08559111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYX91051Medicare PIN