Provider Demographics
NPI:1699233460
Name:MOLLO, MARC JOSEPH (ATC)
Entity type:Individual
Prefix:MR
First Name:MARC
Middle Name:JOSEPH
Last Name:MOLLO
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 PENN DR
Mailing Address - Street 2:
Mailing Address - City:SEWELL
Mailing Address - State:NJ
Mailing Address - Zip Code:08080-1720
Mailing Address - Country:US
Mailing Address - Phone:609-980-5132
Mailing Address - Fax:
Practice Address - Street 1:2755 AUGUSTINE HERMAN HWY
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE CITY
Practice Address - State:MD
Practice Address - Zip Code:21915-1408
Practice Address - Country:US
Practice Address - Phone:410-885-2075
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-11
Last Update Date:2019-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA00009952255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer