Provider Demographics
NPI:1609149335
Name:CHERYL D. MARTIN
Entity Type:Organization
Organization Name:CHERYL D. MARTIN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RN
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:D
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:REGISTERED NURSE
Authorized Official - Phone:631-475-8819
Mailing Address - Street 1:93 BARRETTS AVE
Mailing Address - Street 2:
Mailing Address - City:HOLTSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11742-2114
Mailing Address - Country:US
Mailing Address - Phone:631-475-8819
Mailing Address - Fax:
Practice Address - Street 1:93 BARRETTS AVE
Practice Address - Street 2:
Practice Address - City:HOLTSVILLE
Practice Address - State:NY
Practice Address - Zip Code:11742-2114
Practice Address - Country:US
Practice Address - Phone:631-475-8819
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-10
Last Update Date:2012-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY420290-1251J00000X, 313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
No251J00000XAgenciesNursing Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY=========Medicaid