Provider Demographics
NPI:1598164139
Name:MARTIN, HAZEL FERN (MAC ACA)
Entity Type:Individual
Prefix:
First Name:HAZEL
Middle Name:FERN
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MAC ACA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1640 KERR STREET, LOT 2
Mailing Address - Street 2:
Mailing Address - City:OPELOUSAS
Mailing Address - State:LA
Mailing Address - Zip Code:70570-7845
Mailing Address - Country:US
Mailing Address - Phone:337-212-9899
Mailing Address - Fax:
Practice Address - Street 1:1640 KERR STREET, LOT 2
Practice Address - Street 2:
Practice Address - City:OPELOUSAS
Practice Address - State:LA
Practice Address - Zip Code:70570-7845
Practice Address - Country:US
Practice Address - Phone:337-212-9899
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-20
Last Update Date:2014-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAACA.200026171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist