Provider Demographics
NPI:1750445128
Name:MARTINO, LEAH RUTH (LAC)
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:RUTH
Last Name:MARTINO
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:LEAH
Other - Middle Name:RUTH
Other - Last Name:MARTINO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LAC
Mailing Address - Street 1:3559 ROUND BARN BLVD
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-1763
Mailing Address - Country:US
Mailing Address - Phone:707-571-3935
Mailing Address - Fax:707-571-3298
Practice Address - Street 1:3559 ROUND BARN BLVD
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-1763
Practice Address - Country:US
Practice Address - Phone:707-571-3935
Practice Address - Fax:707-571-3298
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA1537171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist