Healthcare Provider Details

I. General information

NPI: 1538003926
Provider Name (Legal Business Name): MR. ROSENDO MARTINEZ MIRELES SR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2026
Last Update Date: 04/24/2026
Certification Date: 04/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1441 LANSING AVE
LANSING MI
48915-2212
US

IV. Provider business mailing address

1441 LANSING AVE
LANSING MI
48915-2212
US

V. Phone/Fax

Practice location:
  • Phone: 877-912-3795
  • Fax:
Mailing address:
  • Phone: 877-912-3795
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: