Healthcare Provider Details

I. General information

NPI: 1346362803
Provider Name (Legal Business Name): KEVIN F MARTIN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2511 LONG BEACH BLVD
LONG BEACH CA
90806-3111
US

IV. Provider business mailing address

4313 S NORMANDIE AVE
LOS ANGELES CA
90037-2326
US

V. Phone/Fax

Practice location:
  • Phone: 562-981-1501
  • Fax: 562-981-1502
Mailing address:
  • Phone: 323-810-1942
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: