Provider Demographics
NPI:1326286790
Name:GENTRY MARTIAL ARTS
Entity Type:Organization
Organization Name:GENTRY MARTIAL ARTS
Other - Org Name:GMAM
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:
Authorized Official - Last Name:SIEG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-342-5600
Mailing Address - Street 1:PO BOX 1414
Mailing Address - Street 2:
Mailing Address - City:MARTINSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46151-0414
Mailing Address - Country:US
Mailing Address - Phone:765-342-5600
Mailing Address - Fax:765-342-5605
Practice Address - Street 1:333 W. WASHIGTON ST.
Practice Address - Street 2:
Practice Address - City:MARTINSVILLE
Practice Address - State:IN
Practice Address - Zip Code:46151-1431
Practice Address - Country:US
Practice Address - Phone:765-342-5600
Practice Address - Fax:765-342-5605
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-23
Last Update Date:2009-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200918350 AMedicaid