1104910785 NPI number — MARTIN THERAPY

Table of content: MISS MALINDA ANN KNIBBS LMT (NPI 1114192143)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104910785 NPI number — MARTIN THERAPY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARTIN THERAPY
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:
Provider Other Organization Name Type Code:
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:
1104910785
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:
25 ARROYO RIDGE ROAD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALAMOGORDO
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
88310
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-443-8210
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
25 ARROYO RIDGE ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALAMOGORDO
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88310
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-443-8210
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MARTIN
Authorized Official First Name:
SHAWNA
Authorized Official Middle Name:
ROCHELLE
Authorized Official Title or Position:
P.T.
Authorized Official Telephone Number:
505-443-8210

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  1662 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1662 . This is a "NM PT LICENSE" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 000K8676 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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