Provider Demographics
NPI:1457518052
Name:STALLWORTH, MARVIN ALEXANDER
Entity Type:Individual
Prefix:
First Name:MARVIN
Middle Name:ALEXANDER
Last Name:STALLWORTH
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 1:339 E MAIN ST STE 203
Mailing Address - Street 2:
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29730-5367
Mailing Address - Country:US
Mailing Address - Phone:803-746-7749
Mailing Address - Fax:803-746-7748
Practice Address - Street 1:339 E MAIN ST STE 203
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29730-5367
Practice Address - Country:US
Practice Address - Phone:803-746-7749
Practice Address - Fax:803-746-7748
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-21
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide