Healthcare Provider Details

I. General information

NPI: 1205698230
Provider Name (Legal Business Name): JAN MARTINUS LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2024
Last Update Date: 01/25/2024
Certification Date: 01/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11945 CONQUEST ST
BIRCH RUN MI
48415-9294
US

IV. Provider business mailing address

9200 CANADA RD
BIRCH RUN MI
48415-9213
US

V. Phone/Fax

Practice location:
  • Phone: 989-624-9293
  • Fax:
Mailing address:
  • Phone: 989-327-8548
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number7501008681
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: