Provider Demographics
NPI:1033696497
Name:MARTINEZ, CARMEN LUCIA (MS,RD)
Entity Type:Individual
Prefix:
First Name:CARMEN
Middle Name:LUCIA
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:MS,RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1441 EASTLAKE AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90089-1019
Mailing Address - Country:US
Mailing Address - Phone:323-865-3893
Mailing Address - Fax:323-865-3684
Practice Address - Street 1:1441 EASTLAKE AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90089-1019
Practice Address - Country:US
Practice Address - Phone:323-865-3893
Practice Address - Fax:323-865-3684
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-27
Last Update Date:2018-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA804683133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered