Healthcare Provider Details

I. General information

NPI: 1073705661
Provider Name (Legal Business Name): MARTIN LM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2007
Last Update Date: 10/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9801 PENN AVE S
BLOOMINGTON MN
55431-2912
US

IV. Provider business mailing address

1401 E 100TH ST
BLOOMINGTON MN
55425-2615
US

V. Phone/Fax

Practice location:
  • Phone: 952-888-5405
  • Fax:
Mailing address:
  • Phone: 952-888-7751
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number StateMN

VIII. Authorized Official

Name: DENVER KAUFMAN
Title or Position: PRESIDENT
Credential:
Phone: 612-371-0053