Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111N00000X | Chiropractor | 2129 | WI |
NPI | 1003032731 |
---|---|
Provider Name | Dr. Eugene Dale Martin |
First Address | Loyal, WI 54446 |
Second Address | Greenwood, WI 54437-0214 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 18/04/2007 |
Last Update Date | 09/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
38911700 | (05) | WI |