1235796681 NPI number — MARVERLY ENTERPRISES, LLC

Table of content: KELLY ASHLAN CLINE MD (NPI 1700382140)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235796681 NPI number — MARVERLY ENTERPRISES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARVERLY ENTERPRISES, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1235796681
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/21/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 176
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CUBERO
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87014-0176
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-382-5876
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1405 NM HWY 124
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CUBERO
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87014
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-382-5876
Provider Business Practice Location Address Fax Number:
505-933-3458
Provider Enumeration Date:
05/21/2019

Additional Information

Authorized Official

Authorized Official Last Name:
HAMPTON
Authorized Official First Name:
MARK
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
505-382-5876

Provider Taxonomy Codes

  • Taxonomy code: 374U00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3627 . This is a "HOME HEALTH CARE AGENCY" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com