Provider Demographics
NPI:1093743858
Name:MARTIN, KENNETH JR (AUD)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:
Last Name:MARTIN
Suffix:JR
Gender:M
Credentials:AUD
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 3324
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75606-3324
Mailing Address - Country:US
Mailing Address - Phone:903-234-8151
Mailing Address - Fax:903-234-8758
Practice Address - Street 1:710 N HIGH ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75601-5330
Practice Address - Country:US
Practice Address - Phone:903-234-8151
Practice Address - Fax:903-234-8758
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-29
Last Update Date:2010-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX51369231H00000X, 237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter