Healthcare Provider Details

I. General information

NPI: 1326456120
Provider Name (Legal Business Name): MARIO ALFREDO MARTINEZ CHAVEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2014
Last Update Date: 07/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 WILSHIRE BLVD
LOS ANGELES CA
90017-1901
US

IV. Provider business mailing address

700 N ALEXANDER ST
SAN FERNANDO CA
91340-2002
US

V. Phone/Fax

Practice location:
  • Phone: 213-977-2423
  • Fax:
Mailing address:
  • Phone: 818-970-9258
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95000992
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: