Provider Demographics
NPI:1194049064
Name:MARTIN CHILDREN'S CLINIC, LLC
Entity type:Organization
Organization Name:MARTIN CHILDREN'S CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:PIERCE
Authorized Official - Last Name:PAGE
Authorized Official - Suffix:
Authorized Official - Credentials:APN
Authorized Official - Phone:731-587-5138
Mailing Address - Street 1:130 COMMONS DR
Mailing Address - Street 2:
Mailing Address - City:MARTIN
Mailing Address - State:TN
Mailing Address - Zip Code:38237-3879
Mailing Address - Country:US
Mailing Address - Phone:731-587-5138
Mailing Address - Fax:731-587-0552
Practice Address - Street 1:130 COMMONS DR
Practice Address - Street 2:
Practice Address - City:MARTIN
Practice Address - State:TN
Practice Address - Zip Code:38237-3879
Practice Address - Country:US
Practice Address - Phone:731-587-5138
Practice Address - Fax:731-587-0552
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-22
Last Update Date:2017-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN12549261QR1300X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Multi-Specialty