Healthcare Provider Details

I. General information

NPI: 1104760511
Provider Name (Legal Business Name): CAROLINA MENCHACA MARTINEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2026
Last Update Date: 04/16/2026
Certification Date: 04/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7150 BROCKTON AVE STE 103
RIVERSIDE CA
92506-2614
US

IV. Provider business mailing address

758 PENASCO GRANDE ST
PERRIS CA
92570-4555
US

V. Phone/Fax

Practice location:
  • Phone: 951-683-6370
  • Fax:
Mailing address:
  • Phone: 951-422-8346
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: