Healthcare Provider Details

I. General information

NPI: 1609664804
Provider Name (Legal Business Name): TEDDY JOE MARTIN II LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2025
Last Update Date: 04/28/2025
Certification Date: 04/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3857 TEAYS VALLEY RD
HURRICANE WV
25526-0328
US

IV. Provider business mailing address

2305 JEFFERSON AVE
SAINT ALBANS WV
25177-3205
US

V. Phone/Fax

Practice location:
  • Phone: 304-519-9270
  • Fax: 304-519-9271
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number2013-3120
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: