Healthcare Provider Details

I. General information

NPI: 1881862639
Provider Name (Legal Business Name): THELEMA C MARTIN RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MS. THELMA C MARTIN

II. Dates (important events)

Enumeration Date: 02/14/2008
Last Update Date: 03/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5605 GLENRIDGE DR NE SUITE 1050
ATLANTA GA
30342-1365
US

IV. Provider business mailing address

5605 GLENRIDGE DR NE SUITE 1050
ATLANTA GA
30342-1365
US

V. Phone/Fax

Practice location:
  • Phone: 678-527-0800
  • Fax: 678-244-9010
Mailing address:
  • Phone: 678-527-0800
  • Fax: 678-244-9010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License NumberLD001673
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: