Healthcare Provider Details

I. General information

NPI: 1811573975
Provider Name (Legal Business Name): JERRY SAN MARTIN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/19/2021
Last Update Date: 03/19/2021
Certification Date: 03/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 S. GRAND AVE. BLDG C, STE 213
SANTA ANA CA
92705
US

IV. Provider business mailing address

13002 SHREVE RD
WHITTIER CA
90602-3567
US

V. Phone/Fax

Practice location:
  • Phone: 714-567-7628
  • Fax: 714-567-7633
Mailing address:
  • Phone: 626-378-0348
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: