Healthcare Provider Details

I. General information

NPI: 1366355349
Provider Name (Legal Business Name): CARLOS EDWARD MARTINEZ JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2026
Last Update Date: 09/23/2026
Certification Date: 09/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1103 RUPPEL ST APT 222
PUEBLO CO
81001
US

IV. Provider business mailing address

1103 RUPPEL ST APT 222
PUEBLO CO
81001
US

V. Phone/Fax

Practice location:
  • Phone: 719-357-4066
  • Fax:
Mailing address:
  • Phone: 719-357-4066
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number171897331
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: