Provider Demographics
NPI:1104064401
Name:MARVISTA
Entity type:Organization
Organization Name:MARVISTA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:WILSON
Authorized Official - Last Name:BARNES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-486-7081
Mailing Address - Street 1:4140 FERNCREEK DR
Mailing Address - Street 2:SUITE 802
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28314-2563
Mailing Address - Country:US
Mailing Address - Phone:910-486-7081
Mailing Address - Fax:
Practice Address - Street 1:4140 FERNCREEK DR
Practice Address - Street 2:SUITE 802
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28314-2563
Practice Address - Country:US
Practice Address - Phone:910-486-7081
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-26
Last Update Date:2009-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2758174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty