Provider Demographics
NPI:1669642930
Name:MARTIN CHIROPRACTIC GROUP
Entity Type:Organization
Organization Name:MARTIN CHIROPRACTIC GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:G
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:714-539-8021
Mailing Address - Street 1:12441 MAGNOLIA ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92841-3300
Mailing Address - Country:US
Mailing Address - Phone:714-539-8021
Mailing Address - Fax:
Practice Address - Street 1:12441 MAGNOLIA ST
Practice Address - Street 2:SUITE D
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92841-3300
Practice Address - Country:US
Practice Address - Phone:714-539-8021
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARTIN CHIROPRACTIC GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-03-03
Last Update Date:2008-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11221111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU58755Medicare UPIN