Healthcare Provider Details

I. General information

NPI: 1205084902
Provider Name (Legal Business Name): ANTHONY MARTINEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/05/2008
Last Update Date: 09/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

81880 DOCTOR CARREON BLVD SUITE C-208
INDIO CA
92201-5559
US

IV. Provider business mailing address

81880 DOCTOR CARREON BLVD SUITE C-208
INDIO CA
92201-5559
US

V. Phone/Fax

Practice location:
  • Phone: 951-663-4842
  • Fax:
Mailing address:
  • Phone: 951-663-4842
  • 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: