Organization
MARTIN MEDICAL GROUP LLC
Active
Other names
Utah Home Detox, Cache Ketamine and Mental Health
Organization subpart
No
Provider details
NPI number
Authorized official
COLBY MARTIN (OWNER)
(435) 881-0662
Entity
Organization
Contact information
Practice address
115 GOLF COURSE RD STE E, LOGAN, UT 84321-5934
(435) 999-4059
Mailing address
115 GOLF COURSE RD STE E, LOGAN, UT 84321-5934
(435) 999-4059
Taxonomy
Speciality
Code
Description
License number
State
207P00000X
Emergency Medicine Physician
—
—
207Q00000X
Family Medicine Physician
—
—
363A00000X
Physician Assistant
Primary
—
—
363LP0808X
Psychiatric/Mental Health Nurse Practitioner
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
12627418
CAQH
—
Enumeration date
04/02/2020
Last updated
02/23/2023
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