Provider Demographics
NPI:1164021796
Name:MARTIN, VIDA LYNN
Entity Type:Individual
Prefix:
First Name:VIDA
Middle Name:LYNN
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5969 US HIGHWAY 6
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:OH
Mailing Address - Zip Code:44085-9672
Mailing Address - Country:US
Mailing Address - Phone:440-313-4514
Mailing Address - Fax:
Practice Address - Street 1:5969 US HIGHWAY 6
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:OH
Practice Address - Zip Code:44085-9672
Practice Address - Country:US
Practice Address - Phone:440-313-4514
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-24
Last Update Date:2020-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child