Healthcare Provider Details

I. General information

NPI: 1588159909
Provider Name (Legal Business Name): MARTIN MARTIN JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2018
Last Update Date: 08/18/2021
Certification Date: 08/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1630 E SHAW AVE STE 190
FRESNO CA
93710-8114
US

IV. Provider business mailing address

5132 N PALM AVE # 303
FRESNO CA
93704-2236
US

V. Phone/Fax

Practice location:
  • Phone: 559-475-7860
  • Fax: 559-570-0222
Mailing address:
  • Phone: 559-475-7860
  • Fax: 559-570-0222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-21-52077
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-17-30532
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: