Provider Demographics
NPI:1588322762
Name:REDD, MARVIN
Entity type:Individual
Prefix:
First Name:MARVIN
Middle Name:
Last Name:REDD
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 1:2557 MAUREEN CT
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81506-8504
Mailing Address - Country:US
Mailing Address - Phone:303-990-3498
Mailing Address - Fax:
Practice Address - Street 1:2351 G RD
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81505-9641
Practice Address - Country:US
Practice Address - Phone:970-644-3421
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-03
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORN.0103811163WI0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WI0600XNursing Service ProvidersRegistered NurseInfection Control