Provider Demographics
NPI:1063693729
Name:MARVIN, RONALD L (DC)
Entity type:Individual
Prefix:
First Name:RONALD
Middle Name:L
Last Name:MARVIN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:712 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:OAK GROVE
Mailing Address - State:MO
Mailing Address - Zip Code:64075-8102
Mailing Address - Country:US
Mailing Address - Phone:816-690-8383
Mailing Address - Fax:816-690-8791
Practice Address - Street 1:712 S BROADWAY
Practice Address - Street 2:
Practice Address - City:OAK GROVE
Practice Address - State:MO
Practice Address - Zip Code:64075-8102
Practice Address - Country:US
Practice Address - Phone:816-690-8383
Practice Address - Fax:816-690-8791
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-21
Last Update Date:2007-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO003977111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor