Provider Demographics
NPI:1225162142
Name:MARTIN, KEVIN EARL
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:EARL
Last Name:MARTIN
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:KEVIN
Other - Middle Name:EARL
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:2513 COLORADO BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90041-1004
Mailing Address - Country:US
Mailing Address - Phone:323-254-0917
Mailing Address - Fax:323-254-6411
Practice Address - Street 1:2513 COLORADO BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90041-1004
Practice Address - Country:US
Practice Address - Phone:323-254-0917
Practice Address - Fax:323-254-6411
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2012-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16720111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC16720Medicare ID - Type UnspecifiedCHIROPRACTOR