Provider Demographics
NPI:1396235511
Name:E DAWN MARTIN CACIII LLC
Entity type:Organization
Organization Name:E DAWN MARTIN CACIII LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:CACIII
Authorized Official - Phone:719-930-8801
Mailing Address - Street 1:140 S PARKSIDE DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80910-3129
Mailing Address - Country:US
Mailing Address - Phone:719-358-7338
Mailing Address - Fax:844-273-2340
Practice Address - Street 1:140 S PARKSIDE DR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80910-3129
Practice Address - Country:US
Practice Address - Phone:719-358-7338
Practice Address - Fax:844-273-2340
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-14
Last Update Date:2022-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QR0405X, 261QR0405X
1730-03261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder