Provider Demographics
NPI:1073226437
Name:MARTIN, GARY ROBERT
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:ROBERT
Last Name:MARTIN
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 1:516 LAURAL LN
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:ID
Mailing Address - Zip Code:83847-5190
Mailing Address - Country:US
Mailing Address - Phone:208-610-1686
Mailing Address - Fax:
Practice Address - Street 1:516 LAUREL LANE
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:ID
Practice Address - Zip Code:83847
Practice Address - Country:US
Practice Address - Phone:208-610-1686
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-30
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
253Z00000X
IDCHF-2918310400000X, 253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency
No253Z00000XAgenciesIn Home Supportive Care
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDIDTPID006303Medicaid