Healthcare Provider Details

I. General information

NPI: 1760678189
Provider Name (Legal Business Name): EDWARD L MARTIN MLT-ASCP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/19/2007
Last Update Date: 09/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5901 BROKEN SOUND PKWY STE. 500
BOCA RATON FL
33487-2773
US

IV. Provider business mailing address

15 JOHN DR
ALAMOGORDO NM
88310-9545
US

V. Phone/Fax

Practice location:
  • Phone: 561-367-1175
  • Fax: 561-892-3234
Mailing address:
  • Phone: 505-434-3139
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246Z00000X
TaxonomyOther Specialist/Technologist
License NumberMLT-51881
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: