Healthcare Provider Details

I. General information

NPI: 1821269218
Provider Name (Legal Business Name): VICTOR M. MARTINEZ
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2008
Last Update Date: 03/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3127 W 63RD ST
CHICAGO IL
60629-2719
US

IV. Provider business mailing address

3127 W 63RD ST
CHICAGO IL
60629-2719
US

V. Phone/Fax

Practice location:
  • Phone: 773-925-4184
  • Fax: 773-925-4134
Mailing address:
  • Phone: 773-925-4184
  • Fax: 773-925-4134

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number StateIL

VIII. Authorized Official

Name: MR. VICTOR M MARTINEZ
Title or Position: OWNER
Credential: CERTIFIED PEDORTHIST
Phone: 773-925-4184