Healthcare Provider Details

I. General information

NPI: 1710457536
Provider Name (Legal Business Name): TIFFANY M MARTIN DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2018
Last Update Date: 12/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12468 SAINT CHARLES ROCK RD
BRIDGETON MO
63044-2506
US

IV. Provider business mailing address

600 OAKMONT LN STE 600C
WESTMONT IL
60559-5548
US

V. Phone/Fax

Practice location:
  • Phone: 314-739-1123
  • Fax: 314-739-1173
Mailing address:
  • Phone: 630-575-1980
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: