Provider Demographics
NPI:1023165008
Name:ROGER A MARTIN
Entity type:Organization
Organization Name:ROGER A MARTIN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-687-3012
Mailing Address - Street 1:315 E. STONE ST.
Mailing Address - Street 2:PO 328
Mailing Address - City:STURGEON
Mailing Address - State:MO
Mailing Address - Zip Code:65284-0328
Mailing Address - Country:US
Mailing Address - Phone:573-687-3012
Mailing Address - Fax:573-687-1250
Practice Address - Street 1:315 E. STONE ST.
Practice Address - Street 2:PO 328
Practice Address - City:STURGEON
Practice Address - State:MO
Practice Address - Zip Code:65284-0328
Practice Address - Country:US
Practice Address - Phone:573-687-3012
Practice Address - Fax:573-687-1250
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-04
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO032267310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility