Provider Demographics
NPI:1689867707
Name:MARTIN LM LLC
Entity Type:Organization
Organization Name:MARTIN LM LLC
Other - Org Name:MARTIN LUTHER ADULT DAY PROGRAM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DENVER
Authorized Official - Middle Name:
Authorized Official - Last Name:KAUFMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-371-0053
Mailing Address - Street 1:1401 E 100TH ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-2615
Mailing Address - Country:US
Mailing Address - Phone:952-948-5154
Mailing Address - Fax:
Practice Address - Street 1:1401 E 100TH ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55425-2615
Practice Address - Country:US
Practice Address - Phone:952-948-5154
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARTIN LM LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-08-22
Last Update Date:2008-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN640027100Medicaid