Provider Demographics
NPI:1477614741
Name:LEMUEL C & ELMEZEN MARTIN
Entity Type:Organization
Organization Name:LEMUEL C & ELMEZEN MARTIN
Other - Org Name:QUAIL RUN PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICAL THERAPIST OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:LEMUEL
Authorized Official - Middle Name:CAMPOMANES
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:707-263-6845
Mailing Address - Street 1:PO BOX 1560
Mailing Address - Street 2:
Mailing Address - City:LAKEPORT
Mailing Address - State:CA
Mailing Address - Zip Code:95453-1560
Mailing Address - Country:US
Mailing Address - Phone:707-263-6845
Mailing Address - Fax:707-263-6451
Practice Address - Street 1:422 LAKEPORT BLVD
Practice Address - Street 2:
Practice Address - City:LAKEPORT
Practice Address - State:CA
Practice Address - Zip Code:95453-5404
Practice Address - Country:US
Practice Address - Phone:707-263-6845
Practice Address - Fax:707-263-6451
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2015-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT11399225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ06870ZOtherMEDICARE PTAN