Provider Demographics
NPI:1205991304
Name:MARTIN, TRACIE K (DC)
Entity type:Individual
Prefix:
First Name:TRACIE
Middle Name:K
Last Name:MARTIN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2930 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SOQUEL
Mailing Address - State:CA
Mailing Address - Zip Code:95073
Mailing Address - Country:US
Mailing Address - Phone:831-475-2230
Mailing Address - Fax:831-475-1962
Practice Address - Street 1:2930 MAIN ST
Practice Address - Street 2:
Practice Address - City:SOQUEL
Practice Address - State:CA
Practice Address - Zip Code:95073
Practice Address - Country:US
Practice Address - Phone:831-475-2230
Practice Address - Fax:831-475-1962
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-27
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA24744111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0247440Medicare ID - Type Unspecified