Provider Demographics
NPI:1962686964
Name:GERALD MARTINEZ, LLC
Entity Type:Organization
Organization Name:GERALD MARTINEZ, LLC
Other - Org Name:SUMMER HOUSE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LARESA
Authorized Official - Middle Name:OSBORNE
Authorized Official - Last Name:TEEKEL
Authorized Official - Suffix:
Authorized Official - Credentials:QMRP
Authorized Official - Phone:225-933-7488
Mailing Address - Street 1:32649 PERKINS RD
Mailing Address - Street 2:
Mailing Address - City:DENHAM SPRINGS
Mailing Address - State:LA
Mailing Address - Zip Code:70706-1152
Mailing Address - Country:US
Mailing Address - Phone:225-933-7488
Mailing Address - Fax:
Practice Address - Street 1:32649 PERKINS RD
Practice Address - Street 2:
Practice Address - City:DENHAM SPRINGS
Practice Address - State:LA
Practice Address - Zip Code:70706-1152
Practice Address - Country:US
Practice Address - Phone:225-933-7488
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-27
Last Update Date:2015-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1718327Medicare PIN