Healthcare Provider Details

I. General information

NPI: 1346164043
Provider Name (Legal Business Name): MR. MARTINS EBOMA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2026
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3953 HAYGOOD MEADOW DR SW
MARIETTA GA
30062-6517
US

IV. Provider business mailing address

3953 HAYGOOD MEADOW DR SW
MARIETTA GA
30062-6517
US

V. Phone/Fax

Practice location:
  • Phone: 404-322-7292
  • Fax:
Mailing address:
  • Phone: 404-322-7292
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License NumberPHCP011963
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: