Provider Demographics
NPI:1649247750
Name:MARTIAL ART ACADEMY
Entity type:Organization
Organization Name:MARTIAL ART ACADEMY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:LEROY
Authorized Official - Last Name:BLOCKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-642-5723
Mailing Address - Street 1:1302 WHISKEY RD
Mailing Address - Street 2:
Mailing Address - City:AIKEN
Mailing Address - State:SC
Mailing Address - Zip Code:29803-5308
Mailing Address - Country:US
Mailing Address - Phone:803-642-5723
Mailing Address - Fax:803-642-1158
Practice Address - Street 1:1302 WHISKEY RD
Practice Address - Street 2:
Practice Address - City:AIKEN
Practice Address - State:SC
Practice Address - Zip Code:29803-5308
Practice Address - Country:US
Practice Address - Phone:803-642-5723
Practice Address - Fax:803-642-1158
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCMC0061Medicaid