Healthcare Provider Details

I. General information

NPI: 1598169930
Provider Name (Legal Business Name): SAMMY MARTINEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/14/2014
Last Update Date: 10/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5310 SEQUOIA RD NW
ALBUQUERQUE NM
87120-1249
US

IV. Provider business mailing address

5310 SEQUOIA RD NW
ALBUQUERQUE NM
87120-1249
US

V. Phone/Fax

Practice location:
  • Phone: 505-352-3062
  • Fax:
Mailing address:
  • Phone: 505-352-3062
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License NumberX-08804
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: