Healthcare Provider Details

I. General information

NPI: 1669652558
Provider Name (Legal Business Name): MARTIN HEALTH CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2007
Last Update Date: 11/07/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

218 EAST MAIN ST
FLORENCE MS
39073-0530
US

IV. Provider business mailing address

PO BOX 530
FLORENCE MS
39073-0530
US

V. Phone/Fax

Practice location:
  • Phone: 601-845-6602
  • Fax: 601-845-6164
Mailing address:
  • Phone: 601-845-6602
  • Fax: 601-845-6164

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR814098
License Number StateMS

VIII. Authorized Official

Name: MRS. KELLEY MARTIN
Title or Position: NURSE PRACTITIONER- PRESIDENT
Credential: CFNP
Phone: 601-845-6602