Provider Demographics
NPI:1609077825
Name:MARTINE, HEIDI MERCEDES (LAC)
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:MERCEDES
Last Name:MARTINE
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42445 FIJI WAY
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92592-7107
Mailing Address - Country:US
Mailing Address - Phone:951-694-1485
Mailing Address - Fax:
Practice Address - Street 1:28900 OLD TOWN FRONT ST
Practice Address - Street 2:STE. 103
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92590-2856
Practice Address - Country:US
Practice Address - Phone:951-694-1485
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6589171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist