Provider Demographics
NPI:1417395187
Name:MARTINEZ, THOR (BA)
Entity Type:Individual
Prefix:
First Name:THOR
Middle Name:
Last Name:MARTINEZ
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6661 SILVERSTREAM AVE APT 2072
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89107-1173
Mailing Address - Country:US
Mailing Address - Phone:702-486-0464
Mailing Address - Fax:702-486-7656
Practice Address - Street 1:6171 W CHARLESTON BLVD BLDG 11W
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146-1126
Practice Address - Country:US
Practice Address - Phone:702-486-0464
Practice Address - Fax:702-486-7656
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-04
Last Update Date:2013-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator