Healthcare Provider Details

I. General information

NPI: 1942743422
Provider Name (Legal Business Name): KYLE JAMES MARTINOS DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2016
Last Update Date: 09/03/2024
Certification Date: 09/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3832 E MAIN ST SUITE E
FARMINGTON NM
87402-8749
US

IV. Provider business mailing address

PO BOX 370
FORTSON GA
31808-0370
US

V. Phone/Fax

Practice location:
  • Phone: 505-258-4003
  • Fax: 505-436-2740
Mailing address:
  • Phone:
  • Fax: 706-494-3008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPTH8918
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code2251E1300X
TaxonomyClinical Electrophysiology Physical Therapist
License NumberPTH8918
License Number StateAL
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: