=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619978798
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL LEONARD MARTY D.C.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/10/2005
-----------------------------------------------------
Last Update Date | 01/17/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 510 HWY 55 EAST
-----------------------------------------------------
City | KIMBALL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55353
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 320-398-7900
-----------------------------------------------------
Fax | 320-398-7902
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 371
-----------------------------------------------------
City | KIMBALL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55353-0371
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 320-398-7900
-----------------------------------------------------
Fax | 320-398-7902
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 2068
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------