Healthcare Provider Details

I. General information

NPI: 1336633841
Provider Name (Legal Business Name): MANUEL MARTINEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2018
Last Update Date: 05/18/2020
Certification Date: 05/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2080 S E ST STE 200
SAN BERNARDINO CA
92408
US

IV. Provider business mailing address

2080 S E ST STE 200
SAN BERNARDINO CA
92408-2746
US

V. Phone/Fax

Practice location:
  • Phone: 909-388-9191
  • Fax:
Mailing address:
  • Phone: 909-388-9191
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number103540
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number103540
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: