Basic Information
| Provider Information | |||||||||
| NPI: | 1780098111 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | CARLY | ||||||||
| MiddleName: | LINN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 975 SERENO DR | ||||||||
| Address2: | KAISER FOUNDATION REHABILITATION CENTER | ||||||||
| City: | VALLEJO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945892441 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7076511000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 975 SERENO DR | ||||||||
| Address2: | |||||||||
| City: | VALLEJO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945892441 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7076512198 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2014 | ||||||||
| LastUpdateDate: | 01/03/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 40332 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.