Healthcare Provider Details

I. General information

NPI: 1285179424
Provider Name (Legal Business Name): CAITLYN MARTIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/26/2016
Last Update Date: 12/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 W 44TH PL
SIOUX FALLS SD
57105-6376
US

IV. Provider business mailing address

4721 W ANTELOPE DR
SIOUX FALLS SD
57107-6821
US

V. Phone/Fax

Practice location:
  • Phone: 605-322-3278
  • Fax:
Mailing address:
  • Phone: 605-759-2655
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number0455
License Number StateSD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: