Provider Demographics
NPI:1659194918
Name:DEADLOCK, MAVEN
Entity type:Individual
Prefix:
First Name:MAVEN
Middle Name:
Last Name:DEADLOCK
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:743 JENNINGS LN
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22610-2573
Mailing Address - Country:US
Mailing Address - Phone:802-465-2620
Mailing Address - Fax:
Practice Address - Street 1:8282 WILLETT PKWY
Practice Address - Street 2:
Practice Address - City:BALDWINSVILLE
Practice Address - State:NY
Practice Address - Zip Code:13027-1306
Practice Address - Country:US
Practice Address - Phone:315-857-0800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-05
Last Update Date:2024-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist