Healthcare Provider Details

I. General information

NPI: 1164029401
Provider Name (Legal Business Name): CHRISTOPHER MARTIN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/08/2020
Last Update Date: 10/08/2020
Certification Date: 10/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

143 TRUMP AVE
OAK HILL WV
25901-2424
US

IV. Provider business mailing address

143 TRUMP AVE
OAK HILL WV
25901-2424
US

V. Phone/Fax

Practice location:
  • Phone: 304-237-5051
  • Fax:
Mailing address:
  • Phone: 304-237-5051
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number2394-9968
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: