Provider Demographics
NPI:1659980332
Name:MARTIN, RACIA SERENE
Entity Type:Individual
Prefix:MS
First Name:RACIA
Middle Name:SERENE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 KELFORD PL
Mailing Address - Street 2:
Mailing Address - City:TROTWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:45426-2229
Mailing Address - Country:US
Mailing Address - Phone:937-718-9153
Mailing Address - Fax:
Practice Address - Street 1:820 KELFORD PL
Practice Address - Street 2:
Practice Address - City:TROTWOOD
Practice Address - State:OH
Practice Address - Zip Code:45426-2229
Practice Address - Country:US
Practice Address - Phone:937-718-9153
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-28
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH253Z00000X, 372600000X, 374U00000X
376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty
No253Z00000XAgenciesIn Home Supportive Care
No372600000XNursing Service Related ProvidersAdult CompanionGroup - Single Specialty
No376J00000XNursing Service Related ProvidersHomemakerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0241240Medicaid