Healthcare Provider Details

I. General information

NPI: 1568968782
Provider Name (Legal Business Name): LETICIA MARTINEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2018
Last Update Date: 04/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 CAMINO DE LA REINA STE 100A
SAN DIEGO CA
92108-3002
US

IV. Provider business mailing address

123 CAMINO DE LE REINA, SUITE 100A
SAN DIEGO CA
92108
US

V. Phone/Fax

Practice location:
  • Phone: 619-363-0853
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246YR1600X
TaxonomyRegistered Record Administrator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: