Healthcare Provider Details

I. General information

NPI: 1124959879
Provider Name (Legal Business Name): KELCEY MARTIN
Entity Type: Individual
Gender:
Sole Proprietor: N

Provider Other Name: KAM MARTIN

II. Dates (important events)

Enumeration Date: 05/28/2026
Last Update Date: 05/28/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27401 LOS ALTOS STE 300
MISSION VIEJO CA
92691-7608
US

IV. Provider business mailing address

1100 CALLE DEL CERRO APT 244
SAN CLEMENTE CA
92672-9326
US

V. Phone/Fax

Practice location:
  • Phone: 406-217-8178
  • Fax:
Mailing address:
  • Phone: 406-217-8178
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number90662
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: