Healthcare Provider Details

I. General information

NPI: 1861808545
Provider Name (Legal Business Name): RUDY MARTINEZ III
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2014
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date: 12/10/2025
Reactivation Date: 12/17/2025

III. Provider practice location address

1133 COLOMA WAY
ROSEVILLE CA
95661-4480
US

IV. Provider business mailing address

6346 BONHAM CIR
CITRUS HEIGHTS CA
95610-5914
US

V. Phone/Fax

Practice location:
  • Phone: 916-774-6647
  • Fax:
Mailing address:
  • Phone: 916-749-0146
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: