Provider Demographics
NPI:1861981912
Name:MURDOCK, MARLON BENTLEY (BENTLEY)
Entity type:Individual
Prefix:
First Name:MARLON
Middle Name:BENTLEY
Last Name:MURDOCK
Suffix:
Gender:M
Credentials:BENTLEY
Other - Prefix:
Other - First Name:BENTLEY
Other - Middle Name:
Other - Last Name:MURDOCK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:180 N MAIN ST STE 98
Mailing Address - Street 2:
Mailing Address - City:SAINT GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84770-9997
Mailing Address - Country:US
Mailing Address - Phone:805-215-0110
Mailing Address - Fax:
Practice Address - Street 1:142 E 500 S APT 2
Practice Address - Street 2:
Practice Address - City:SAINT GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770-3629
Practice Address - Country:US
Practice Address - Phone:805-215-0110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-04
Last Update Date:2018-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT001OtherMOVARA FITNESS RESORT