Provider Demographics
NPI:1013770148
Name:PROVIDER ON DEMAND LLC
Entity type:Organization
Organization Name:PROVIDER ON DEMAND LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:DR
Authorized Official - First Name:BRETT
Authorized Official - Middle Name:
Authorized Official - Last Name:MARVEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:737-747-2200
Mailing Address - Street 1:1551 W CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:TEMPLE
Mailing Address - State:TX
Mailing Address - Zip Code:76504-4005
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1199 OLD LORENA RD
Practice Address - Street 2:
Practice Address - City:LORENA
Practice Address - State:TX
Practice Address - Zip Code:76655-3176
Practice Address - Country:US
Practice Address - Phone:757-642-5062
Practice Address - Fax:737-270-7540
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-01
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty