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General NPI Number Information
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NPI Number | 1255523858
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Entity Type | Organization
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Legal Business Name | MARTIN LM LLC
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Dates
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Enumeration Date | 08/16/2007
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Last Update Date | 12/17/2008
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Provider Practice Location Address
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Address Line | 4616 W 102ND ST
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City | BLOOMINGTON
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State | MN
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Zip | 55437-2612
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Country | US
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Telephone | 952-893-9078
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Fax |
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Provider Business Mailing Address
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Address Line | 1401 E 100TH ST
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City | BLOOMINGTON
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State | MN
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Zip | 55425-2615
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Country | US
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Telephone | 952-888-7751
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DENVER KAUFMAN
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Credential |
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Telephone | 612-371-0053
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 311ZA0620X
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Taxonomy Name | Adult Care Home Facility
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License Number | 1045533-1
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License Number State | MN
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