1194939405 NPI number — DR. LARRY MARTIN

Table of content: (NPI 1194939405)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194939405 NPI number — DR. LARRY MARTIN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DR. LARRY MARTIN
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
LBL ESD
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194939405
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
905 4TH AVE SE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALBANY
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97321-3104
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-812-2600
Provider Business Mailing Address Fax Number:
541-926-6047

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
905 4TH AVE SE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALBANY
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97321-3104
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-812-2600
Provider Business Practice Location Address Fax Number:
541-926-6047
Provider Enumeration Date:
05/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
TAYLOR
Authorized Official First Name:
JON
Authorized Official Middle Name:
E
Authorized Official Title or Position:
BUSINESS SERVICES DIRECTOR
Authorized Official Telephone Number:
541-812-2600

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  062028 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: NEW APPLICATION , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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