Provider Demographics
NPI:1467081448
Name:MARTIN MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:MARTIN MEDICAL GROUP LLC
Other - Org Name:CACHE KETAMINE AND MENTAL HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:COLBY
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-881-0662
Mailing Address - Street 1:115 GOLF COURSE RD STE E
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84321-5934
Mailing Address - Country:US
Mailing Address - Phone:435-999-4059
Mailing Address - Fax:
Practice Address - Street 1:115 GOLF COURSE RD STE E
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84321-5934
Practice Address - Country:US
Practice Address - Phone:435-999-4059
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-02
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental HealthGroup - Multi-Specialty
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
12627418OtherCAQH