Provider Demographics
NPI:1740837798
Name:DOLE, MARTIN R (RN)
Entity type:Individual
Prefix:
First Name:MARTIN
Middle Name:R
Last Name:DOLE
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7176 MARGATE CT
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91739-1865
Mailing Address - Country:US
Mailing Address - Phone:626-226-6014
Mailing Address - Fax:
Practice Address - Street 1:2295 S VINEYARD AVE
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91761-7925
Practice Address - Country:US
Practice Address - Phone:909-724-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-23
Last Update Date:2019-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA647522163WE0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WE0003XNursing Service ProvidersRegistered NurseEmergency