Basic Information
| Provider Information | |||||||||
| NPI: | 1104293950 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTINIS | ||||||||
| FirstName: | KYLE | ||||||||
| MiddleName: | EDWIN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PT, DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 237 WINTHROP ST | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | REHOBOTH | ||||||||
| State: | MA | ||||||||
| PostalCode: | 027692601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7745650796 | ||||||||
| FaxNumber: | 7745658346 | ||||||||
| Practice Location | |||||||||
| Address1: | 65 HOLBROOK ST STE 130 | ||||||||
| Address2: | |||||||||
| City: | NORFOLK | ||||||||
| State: | MA | ||||||||
| PostalCode: | 020561849 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7745650796 | ||||||||
| FaxNumber: | 7745658346 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/27/2015 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 1264012 | TX | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 22262 | MA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.