Provider Demographics
NPI:1952758898
Name:MARTIN, LA SHADA KAI
Entity type:Individual
Prefix:MS
First Name:LA SHADA
Middle Name:KAI
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13010 KORNBLUM AVE
Mailing Address - Street 2:UNIT D
Mailing Address - City:HAWTHORNE
Mailing Address - State:CA
Mailing Address - Zip Code:90250-0423
Mailing Address - Country:US
Mailing Address - Phone:310-462-0631
Mailing Address - Fax:
Practice Address - Street 1:13010 KORNBLUM AVE
Practice Address - Street 2:UNIT D
Practice Address - City:HAWTHORNE
Practice Address - State:CA
Practice Address - Zip Code:90250
Practice Address - Country:US
Practice Address - Phone:310-462-0631
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-20
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No171W00000XOther Service ProvidersContractor