=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831777978
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARTIN CARDENAS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/30/2021
-----------------------------------------------------
Last Update Date | 03/30/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1235 GABLES DR NE
-----------------------------------------------------
City | BROOKHAVEN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30319-4192
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 915-777-2224
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1235 GABLES DR NE
-----------------------------------------------------
City | BROOKHAVEN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30319-4192
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 915-777-2224
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | MT013398
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------