Provider Demographics
NPI:1891361564
Name:MARTINEZ-CHAVOLLA, JUAN
Entity Type:Individual
Prefix:MR
First Name:JUAN
Middle Name:
Last Name:MARTINEZ-CHAVOLLA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1477
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92393-1477
Mailing Address - Country:US
Mailing Address - Phone:760-243-3999
Mailing Address - Fax:
Practice Address - Street 1:14344 CAJON AVE STE 101-103
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92392-4300
Practice Address - Country:US
Practice Address - Phone:760-243-3999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-02
Last Update Date:2021-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator