Provider Demographics
NPI:1790120384
Name:MARTIN LIVING CORPORATION
Entity Type:Organization
Organization Name:MARTIN LIVING CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MISS
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:RIDGELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-658-1254
Mailing Address - Street 1:PO BOX 2201
Mailing Address - Street 2:61 THOMAS DICKENS ROAD
Mailing Address - City:LILLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27546-2201
Mailing Address - Country:US
Mailing Address - Phone:910-658-1254
Mailing Address - Fax:
Practice Address - Street 1:61 THOMAS DICKENS RD
Practice Address - Street 2:61 THOMAS DICKENS ROAD
Practice Address - City:LILLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27546-7606
Practice Address - Country:US
Practice Address - Phone:910-658-1254
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-08
Last Update Date:2014-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-043-090261QA0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0005XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Family Planning Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC043-090Medicaid
NCMHL043090Medicaid
NC120301Medicaid