Provider Demographics
NPI:1982983110
Name:MARTIN, MANUEL DELA CRUZ
Entity Type:Individual
Prefix:
First Name:MANUEL
Middle Name:DELA CRUZ
Last Name:MARTIN
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 1:9941 N SEDONA CIR
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-5410
Mailing Address - Country:US
Mailing Address - Phone:559-314-4114
Mailing Address - Fax:
Practice Address - Street 1:1700 MOUNT VERNON AVE
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93306-4018
Practice Address - Country:US
Practice Address - Phone:661-326-2715
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-05
Last Update Date:2011-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA749551163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health