Provider Demographics
NPI:1194939405
Name:DR. LARRY MARTIN
Entity type:Organization
Organization Name:DR. LARRY MARTIN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUSINESS SERVICES DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JON
Authorized Official - Middle Name:E
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-812-2600
Mailing Address - Street 1:905 4TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:OR
Mailing Address - Zip Code:97321-3104
Mailing Address - Country:US
Mailing Address - Phone:541-812-2600
Mailing Address - Fax:541-926-6047
Practice Address - Street 1:905 4TH AVE SE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:OR
Practice Address - Zip Code:97321-3104
Practice Address - Country:US
Practice Address - Phone:541-812-2600
Practice Address - Fax:541-926-6047
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR062028332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORNEW APPLICATIONMedicaid