MEDICARE: DAVON MARTIN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician		NV

General Provider Information

NPI Number	:	1063178705
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAVON MARTIN

Provider Business Mailing Address
First Line	:	21600 OXNARD ST
Second Line	:
City	:	WOODLAND HILLS
State	:	CA
Zip	:	91367-4976
Country	:	US
Telephone Number	:	818-345-2345
Fax Number	:

Provider Business Practice Location Address
First Line	:	8020 W SAHARA AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89117-7939
Country	:	US
Telephone Number	:	702-470-0620
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/16/2021
Last Update Date	:	06/10/2022

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Directions to “ DAVON MARTIN ” Practice Location

Language	Start Address	Practice Location

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