Healthcare Provider Details

I. General information

NPI: 1811659162
Provider Name (Legal Business Name): MARTIN MOISES TADEO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2021
Last Update Date: 09/20/2023
Certification Date: 09/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2731 NUGGET AVE
LAKE ISABELLA CA
93240
US

IV. Provider business mailing address

2731 NUGGET AVE
LAKE ISABELLA CA
93240
US

V. Phone/Fax

Practice location:
  • Phone: 760-379-3412
  • Fax: 760-379-5332
Mailing address:
  • Phone: 760-379-3412
  • Fax: 760-379-5332

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: