MEDICARE: MARTIN GROUP CARE HOME

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	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility	13578712	MO

General Provider Information

NPI Number	:	1780734996
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARTIN GROUP CARE HOME

Provider Business Mailing Address
First Line	:	3801 S GRAND AVE
Second Line	:
City	:	SEDALIA
State	:	MO
Zip	:	65301-8705
Country	:	US
Telephone Number	:	660-827-7168
Fax Number	:	660-827-5372

Provider Business Practice Location Address
First Line	:	3801 S GRAND AVE
Second Line	:
City	:	SEDALIA
State	:	MO
Zip	:	65301-8705
Country	:	US
Telephone Number	:	660-827-7168
Fax Number	:	660-827-5372

Authorized Official
Title or Position	:	OWNER
Name	:	MS. KATHLEEN MARIE MARTIN
Credential	:
Telephone Number	:	660-827-7168

Provider Enumeration Date	:	01/11/2007
Last Update Date	:	08/22/2020

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