Healthcare Provider Details

I. General information

NPI: 1679755862
Provider Name (Legal Business Name): MANUEL A MARTINEZ RD, CDE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2007
Last Update Date: 11/29/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1025 W OLYMPIC BLVD ROOM 7
LOS ANGELES CA
90015-1329
US

IV. Provider business mailing address

1025 W OLYMPIC BLVD ROOM 7
LOS ANGELES CA
90015-1329
US

V. Phone/Fax

Practice location:
  • Phone: 213-861-5849
  • Fax: 213-861-5973
Mailing address:
  • Phone: 213-861-5849
  • Fax: 213-861-5973

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number833369
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License NumberCDE 2021-0283
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: