Healthcare Provider Details

I. General information

NPI: 1275701401
Provider Name (Legal Business Name): MARTIN AURELIO OTR/L
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/11/2008
Last Update Date: 04/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 W AMERICAN CANYON RD STE 580-279
AMERICAN CANYON CA
94503-1162
US

IV. Provider business mailing address

101 W AMERICAN CANYON RD STE 580-279
AMERICAN CANYON CA
94503-1162
US

V. Phone/Fax

Practice location:
  • Phone: 707-853-0315
  • Fax:
Mailing address:
  • Phone: 707-853-0315
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License NumberOT- 2047
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: