Healthcare Provider Details

I. General information

NPI: 1457809188
Provider Name (Legal Business Name): JEREMIAS MARTINEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2016
Last Update Date: 09/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1212 S 58TH CT
CICERO IL
60804-1116
US

IV. Provider business mailing address

1212 S 58TH CT
CICERO IL
60804-1116
US

V. Phone/Fax

Practice location:
  • Phone: 708-646-8684
  • Fax:
Mailing address:
  • Phone: 708-646-8684
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberM635-4349-1262
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberM635-4349-1262
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: