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General NPI Number Information
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NPI Number | 1700407673
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Entity Type | Individual
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Provider Name | KENNETH MARTIN III OTR/L
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Gender | Male
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Dates
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Enumeration Date | 05/02/2020
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Last Update Date | 05/02/2020
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Provider Practice Location Address
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Address Line | 315 FIELD ST
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City | BREMEN
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State | GA
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Zip | 30110-2105
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Country | US
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Telephone | 770-537-4482
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Fax |
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Provider Business Mailing Address
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Address Line | 6009 ZURICH DR
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City | RICHMOND
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State | VA
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Zip | 23224-4527
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Country | US
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Telephone | 804-972-8010
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number | 0119-008582
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License Number State | VA
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