Provider Demographics
NPI:1043836588
Name:MARTIN VENTURES LLC
Entity Type:Organization
Organization Name:MARTIN VENTURES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHANCE
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-402-0302
Mailing Address - Street 1:4811 W STANFORD ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65802-7773
Mailing Address - Country:US
Mailing Address - Phone:417-402-0302
Mailing Address - Fax:
Practice Address - Street 1:3119 S SCENIC AVE STE B
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-3965
Practice Address - Country:US
Practice Address - Phone:417-402-0302
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-21
Last Update Date:2020-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2014019578OtherPHYSICAL THERAPY LICENSE NUMBER