Provider Demographics
NPI:1073057493
Name:MARTINEZ, MIGUEL (ATC)
Entity Type:Individual
Prefix:
First Name:MIGUEL
Middle Name:
Last Name:MARTINEZ
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5680 E HOMECOMING CIR
Mailing Address - Street 2:UNIT C
Mailing Address - City:EASTVALE
Mailing Address - State:CA
Mailing Address - Zip Code:91752-4258
Mailing Address - Country:US
Mailing Address - Phone:702-686-1753
Mailing Address - Fax:
Practice Address - Street 1:5680 E HOMECOMING CIR
Practice Address - Street 2:UNIT C
Practice Address - City:EASTVALE
Practice Address - State:CA
Practice Address - Zip Code:91752-4258
Practice Address - Country:US
Practice Address - Phone:702-686-1753
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-05
Last Update Date:2016-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20000190072255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer