Healthcare Provider Details

I. General information

NPI: 1700709045
Provider Name (Legal Business Name): MARTY CELIS MPSS-SPEZDN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2026
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44505 90TH ST W BLDG B
LANCASTER CA
93536-7705
US

IV. Provider business mailing address

44505 90TH ST W BLDG B
LANCASTER CA
93536-7705
US

V. Phone/Fax

Practice location:
  • Phone: 661-726-2630
  • Fax:
Mailing address:
  • Phone: 661-726-2630
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberMPSS-SPEZDN
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: