Provider Demographics
NPI:1366761702
Name:MARTIN, MICHAEL (LPT)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:MARTIN
Suffix:
Gender:M
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16460 VICTOR ST
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-3918
Mailing Address - Country:US
Mailing Address - Phone:760-245-8837
Mailing Address - Fax:730-245-8893
Practice Address - Street 1:16460 VICTOR ST
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-3918
Practice Address - Country:US
Practice Address - Phone:760-245-8837
Practice Address - Fax:730-245-8893
Is Sole Proprietor?:No
Enumeration Date:2010-05-25
Last Update Date:2010-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
35430167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician