Provider Demographics
NPI:1619978798
Name:MARTY, MICHAEL LEONARD (DC)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:LEONARD
Last Name:MARTY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 371
Mailing Address - Street 2:
Mailing Address - City:KIMBALL
Mailing Address - State:MN
Mailing Address - Zip Code:55353-0371
Mailing Address - Country:US
Mailing Address - Phone:320-398-7900
Mailing Address - Fax:320-398-7902
Practice Address - Street 1:510 HWY 55 EAST
Practice Address - Street 2:
Practice Address - City:KIMBALL
Practice Address - State:MN
Practice Address - Zip Code:55353
Practice Address - Country:US
Practice Address - Phone:320-398-7900
Practice Address - Fax:320-398-7902
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-10
Last Update Date:2008-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2068111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN230530OtherCHIROCARE
MN3K836KIOtherBLUECROSS BLUE SHIELD