Healthcare Provider Details

I. General information

NPI: 1053850883
Provider Name (Legal Business Name): CRIS MARTINEZ VERDUGO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/13/2017
Last Update Date: 11/04/2025
Certification Date: 11/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8836 S VERMONT AVE
LOS ANGELES CA
90044-4832
US

IV. Provider business mailing address

8836 S VERMONT AVE
LOS ANGELES CA
90044-4832
US

V. Phone/Fax

Practice location:
  • Phone: 323-593-5300
  • Fax:
Mailing address:
  • Phone: 323-921-8803
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCATC #174380I
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL
# 4
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberMPSS-IZUEFK
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: