Provider Demographics
NPI:1912426875
Name:HERBERT, MARC DAVID
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:DAVID
Last Name:HERBERT
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:PO BOX 441146
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30160-9522
Mailing Address - Country:US
Mailing Address - Phone:678-403-3568
Mailing Address - Fax:
Practice Address - Street 1:1615 RIDENOUR BLVD NW STE 204
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30152-4464
Practice Address - Country:US
Practice Address - Phone:770-580-8070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-12
Last Update Date:2017-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist