Healthcare Provider Details

I. General information

NPI: 1497114722
Provider Name (Legal Business Name): JACQUELINE MARTINEZ OTC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/15/2016
Last Update Date: 02/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4201 TORRANCE BLVD SUITE 190
TORRANCE CA
90503
US

IV. Provider business mailing address

24617 AVALON BLVD
WILMINGTON CA
90744
US

V. Phone/Fax

Practice location:
  • Phone: 310-543-2521
  • Fax:
Mailing address:
  • Phone: 424-477-4674
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number08-0833
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: