Provider Demographics
NPI:1649991407
Name:GARRISON, MARK WAYNE SR
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:WAYNE
Last Name:GARRISON
Suffix:SR
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 1:115 CAMP AVE
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24501-6931
Mailing Address - Country:US
Mailing Address - Phone:434-544-1709
Mailing Address - Fax:434-386-8658
Practice Address - Street 1:115 CAMP AVE
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501-6931
Practice Address - Country:US
Practice Address - Phone:434-544-1709
Practice Address - Fax:434-386-8658
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-08
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAT60439260344600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes344600000XTransportation ServicesTaxi