Provider Demographics
NPI:1891171492
Name:MARTIN, GRACE (LMT)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:418 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DAVISON
Mailing Address - State:MI
Mailing Address - Zip Code:48423-1608
Mailing Address - Country:US
Mailing Address - Phone:810-691-1719
Mailing Address - Fax:
Practice Address - Street 1:2284 S BALLENGER HWY
Practice Address - Street 2:STE. F
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48503-3446
Practice Address - Country:US
Practice Address - Phone:810-235-5181
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-05
Last Update Date:2015-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501004326171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor