Provider Demographics
NPI:1669652558
Name:MARTIN HEALTH CARE, LLC
Entity Type:Organization
Organization Name:MARTIN HEALTH CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER- PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:KELLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:CFNP
Authorized Official - Phone:601-845-6602
Mailing Address - Street 1:PO BOX 530
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:MS
Mailing Address - Zip Code:39073-0530
Mailing Address - Country:US
Mailing Address - Phone:601-845-6602
Mailing Address - Fax:601-845-6164
Practice Address - Street 1:218 EAST MAIN ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:MS
Practice Address - Zip Code:39073-0530
Practice Address - Country:US
Practice Address - Phone:601-845-6602
Practice Address - Fax:601-845-6164
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-07
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR814098207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09016100Medicaid
MS09016100Medicaid