Provider Demographics
NPI:1023176021
Name:MARTIN, RANDY (LAC, OMD, QME)
Entity type:Individual
Prefix:DR
First Name:RANDY
Middle Name:
Last Name:MARTIN
Suffix:
Gender:M
Credentials:LAC, OMD, QME
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17000 VENTURA BLVD STE 220
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316-4158
Mailing Address - Country:US
Mailing Address - Phone:818-905-6171
Mailing Address - Fax:
Practice Address - Street 1:17000 VENTURA BLVD STE 220
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316-4158
Practice Address - Country:US
Practice Address - Phone:818-905-6171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA2265171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist