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General NPI Number Information
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NPI Number | 1154504819
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Entity Type | Organization
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Legal Business Name | DR. CRYSTAL MARTIN, LLC
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Dates
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Enumeration Date | 12/17/2007
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Last Update Date | 05/16/2014
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Provider Practice Location Address
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Address Line | 8730 TALLON LN NE SUITE 104
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City | LACEY
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State | WA
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Zip | 98516-6609
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Country | US
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Telephone | 800-689-1254
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Fax |
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Provider Business Mailing Address
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Address Line | 40402 62ND AVE E
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City | EATONVILLE
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State | WA
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Zip | 98328-9599
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Country | US
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Telephone | 405-921-6564
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Fax |
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Authorized Official
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Title or Position | OWNER/ CHIROPRACTOR
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Name | DR. CRYSTAL DAWN MARTIN
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Credential | DC
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Telephone | 405-921-6564
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | CH 60394038
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License Number State | WA
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