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General NPI Number Information
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NPI Number | 1982349833
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Entity Type | Individual
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Provider Name | GLEN WAYNE MARTIN
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Gender | Male
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Dates
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Enumeration Date | 05/04/2022
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Last Update Date | 05/04/2022
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Provider Practice Location Address
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Address Line | 218 N LOGAN AVE
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City | DANVILLE
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State | IL
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Zip | 61832-5655
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Country | US
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Telephone | 217-431-0240
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Fax |
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Provider Business Mailing Address
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Address Line | 108 LAKESIDE DR
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City | DANVILLE
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State | IL
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Zip | 61832-1317
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Country | US
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Telephone | 217-497-0444
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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 | 171WH0202X
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Taxonomy Name | Home Modifications Contractor
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License Number | B-0014
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License Number State | IL
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