Provider Demographics
NPI:1740552272
Name:MARTINEZ, JIM CHRISTOPHER (LAC)
Entity type:Individual
Prefix:MR
First Name:JIM
Middle Name:CHRISTOPHER
Last Name:MARTINEZ
Suffix:
Gender:M
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:PO BOX 2521
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59912-2521
Mailing Address - Country:US
Mailing Address - Phone:406-885-3607
Mailing Address - Fax:
Practice Address - Street 1:4880 US HIGHWAY 93 S
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-7985
Practice Address - Country:US
Practice Address - Phone:406-857-2506
Practice Address - Fax:406-857-2503
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-30
Last Update Date:2012-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT998324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility