Healthcare Provider Details

I. General information

NPI: 1063178705
Provider Name (Legal Business Name): DAVON MARTIN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2021
Last Update Date: 06/10/2022
Certification Date: 06/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8020 W SAHARA AVE
LAS VEGAS NV
89117-7939
US

IV. Provider business mailing address

21600 OXNARD ST
WOODLAND HILLS CA
91367-4976
US

V. Phone/Fax

Practice location:
  • Phone: 702-470-0620
  • Fax:
Mailing address:
  • Phone: 818-345-2345
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: