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General NPI Number Information
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NPI Number | 1194078816
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Entity Type | Organization
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Legal Business Name | VIVIAN L MARTIN
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Dates
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Enumeration Date | 10/18/2012
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Last Update Date | 10/18/2012
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Provider Practice Location Address
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Address Line | 1024 JORDAN ST
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City | MOUNT VERNON
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State | IL
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Zip | 62864-4231
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Country | US
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Telephone | 618-242-4442
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Fax | 618-242-3942
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Provider Business Mailing Address
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Address Line | 1024 JORDAN ST
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City | MOUNT VERNON
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State | IL
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Zip | 62864-4231
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Country | US
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Telephone | 618-242-4442
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Fax | 618-242-3942
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Authorized Official
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Title or Position | OWNER
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Name | VIVIAN LEA MARTIN
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Credential |
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Telephone | 618-242-4442
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 335E00000X
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Taxonomy Name | Prosthetic/Orthotic Supplier
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License Number |
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License Number State |
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