Healthcare Provider Details

I. General information

NPI: 1710594502
Provider Name (Legal Business Name): CHESANEY MARTIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2020
Last Update Date: 09/26/2020
Certification Date: 09/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

424 BAYOU RD
WINTER HAVEN FL
33884-2507
US

IV. Provider business mailing address

424 BAYOU RD
WINTER HAVEN FL
33884-2507
US

V. Phone/Fax

Practice location:
  • Phone: 863-288-5525
  • Fax:
Mailing address:
  • Phone: 863-288-5525
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code227800000X
TaxonomyCertified Respiratory Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: