Provider Demographics
NPI:1346300043
Name:MARTIN, MARK KEVIN
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:KEVIN
Last Name:MARTIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12771 MARTHA ANN DR
Mailing Address - Street 2:
Mailing Address - City:LOS ALAMITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90720-4921
Mailing Address - Country:US
Mailing Address - Phone:562-430-2178
Mailing Address - Fax:562-599-3934
Practice Address - Street 1:1975 LONG BEACH BLVD
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806-5501
Practice Address - Country:US
Practice Address - Phone:562-218-4091
Practice Address - Fax:562-599-3934
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist