Healthcare Provider Details

I. General information

NPI: 1780958488
Provider Name (Legal Business Name): JOSE L MARTIN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2012
Last Update Date: 02/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1722 S LEWIS RD
CAMARILLO CA
93012-8520
US

IV. Provider business mailing address

1722 S LEWIS RD
CAMARILLO CA
93012-8520
US

V. Phone/Fax

Practice location:
  • Phone: 805-445-7800
  • Fax:
Mailing address:
  • Phone: 805-445-7800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: