Healthcare Provider Details

I. General information

NPI: 1932353455
Provider Name (Legal Business Name): MARY ELIZABETH MARTIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/11/2008
Last Update Date: 11/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2930 COUNTY ROAD 4002
HOLTS SUMMIT MO
65043-2079
US

IV. Provider business mailing address

2930 CO.RD.4003
HOLTS SUMMIT MO
65043
US

V. Phone/Fax

Practice location:
  • Phone: 573-295-6684
  • Fax: 573-295-6684
Mailing address:
  • Phone: 573-295-6684
  • Fax: 573-295-6684

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code177F00000X
TaxonomyLodging Provider
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: