Healthcare Provider Details

I. General information

NPI: 1629148929
Provider Name (Legal Business Name): MARTIN LM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 08/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 E 100TH ST
BLOOMINGTON MN
55425
US

IV. Provider business mailing address

1401 E 100TH ST
BLOOMINGTON MN
55425
US

V. Phone/Fax

Practice location:
  • Phone: 952-888-7751
  • Fax: 952-698-3626
Mailing address:
  • Phone: 952-888-7751
  • Fax: 952-698-3626

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number343053
License Number StateMN

VIII. Authorized Official

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