Provider Demographics
NPI:1083622039
Name:MARTIN, LEMUEL CAMPOMANES (PT)
Entity Type:Individual
Prefix:MR
First Name:LEMUEL
Middle Name:CAMPOMANES
Last Name:MARTIN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1560
Mailing Address - Street 2:
Mailing Address - City:LAKEPORT
Mailing Address - State:CA
Mailing Address - Zip Code:95453-1560
Mailing Address - Country:US
Mailing Address - Phone:707-263-4564
Mailing Address - Fax:707-263-4572
Practice Address - Street 1:1281 CRAIG AVENUE
Practice Address - Street 2:
Practice Address - City:LAKEPORT
Practice Address - State:CA
Practice Address - Zip Code:95453
Practice Address - Country:US
Practice Address - Phone:707-263-4564
Practice Address - Fax:707-263-4572
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT11399225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PT11399OtherCOMMERCIAL PIN
ZZZ273982OtherBLUE SHIELD
ZZZ273982OtherBLUE SHIELD