Healthcare Provider Details

I. General information

NPI: 1689657124
Provider Name (Legal Business Name): JUSTIN LOUIS MARTIN PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2005
Last Update Date: 02/12/2025
Certification Date: 02/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 8TH DIVISION RD
COLUMBIA SC
29207-5700
US

IV. Provider business mailing address

2513 BURNEY DR
COLUMBIA SC
29205-3116
US

V. Phone/Fax

Practice location:
  • Phone: 37-512-4088
  • Fax:
Mailing address:
  • Phone: 623-326-9872
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License NumberPT006472
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: