1184310344 NPI number — MRS. ALLISON JEAN MARTIN RD, LD, CPT

Table of content: MRS. ALLISON JEAN MARTIN RD, LD, CPT (NPI 1184310344)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184310344 NPI number — MRS. ALLISON JEAN MARTIN RD, LD, CPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARTIN
Provider First Name:
ALLISON
Provider Middle Name:
JEAN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
RD, LD, CPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BOUSHON
Provider Other First Name:
ALLISON
Provider Other Middle Name:
JEAN
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1184310344
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/12/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
410 S ALCO AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARYVILLE
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64468-2036
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-414-2142
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
410 S ALCO AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARYVILLE
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64468-2036
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-414-2142
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/12/2023

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 133V00000X , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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